SDS Accreditation Update

Want to ace infection control part of your survey? Perform an audit of your hand hygiene program

Outpatient surgery programs around the country are reporting that accreditation survey teams are sending an additional surveyor who targets infection control during the survey process.

"It's a big deal for certification and surveyors," says Richard Bays, RN, MBA, CPHQ, CLNC, of R Bays Consulting in Houston, TX.

Before you undergo a survey, set an initial baseline of compliance by gathering data from direct observation audits of staff, advises Kathleen Richmond, RN, MS, CIC, associate director of the Standards Interpretation Group, Division of Healthcare Improvement at The Joint Commission. [Two handwashing audit tools are included. The Hand Hygiene Monitoring Tool was adapted for larger facilities.]

There is no requirement for that compliance rate, Richmond says. Subsequently, set a realistic compliance goal that is higher than the initial baseline. "For example, an organization may have an initial baseline compliance of 64%, and its first quarterly goal might then be set at 75% followed by 80% for the next quarter," Richmond says.

Have the safety officer or infection control nurse monitor the rate weekly or monthly unless you have a problem that needs to be addressed immediately, Bays suggests. Such problems might include a report of a case infection from improper hand hygiene or not changing gloves between patients, which potentially could lead to an infected surgical wound when a dressing is changed, for example.

At the infection control meetings, discuss the results of your audit and any improvement or problems since your baseline recording, Bays advises. "If there is any deviation toward goals, take appropriate action and record that," he says.

Advertise the results of the audit to members of your staff, he advises. If the results are of your audit are less than 100%, talk about the results, and post updates in lounges or employee newsletters, Bays advises. If it's 100% compliance, tell them to keep up the good work, Bays says. At Spring Surgical Center in The Woodlands, TX, "we reward our staff and celebrate with cake, ice cream, and lunches. It varies," says Elda Navarro, business office manager.

Bays urges you to aim for full compliance. "I think, given a moderate amount of effort, you can reach 100%," he says.

The most important step? Share compliance data, Richmond says. "Staff should then be enlisted to get involved in improving the organization's hand hygiene compliance and take ownership of the results," Richmond says.

All levels of staff should participate with hand hygiene compliance, Bays advises. "It shows some cohesiveness with meeting infection control practices," he says.

What do surveyors expect?

What is one of the most important preventative measures in decreasing healthcare-associated infections (HAIs)? According to Richmond, it is "improving the hand hygiene of healthcare workers."

The Joint Commission's National Patient Safety Goal (NPSG) 07.01.01 requires facilities to comply with hand hygiene guidelines from the Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the World Health Organization (WHO).

"It is essential to the accreditation survey process that an organization fosters a culture of hand hygiene and that appropriate hand hygiene is evident to the surveyors," Richmond says. "An organization with a comprehensive hand hygiene program will have compliance monitoring through direct observation and feedback to the staff in order to promote continual improvement."

Accreditation surveyors will expect that the level of complexity of your hand hygiene program matches the complexity of your program, Bays says. "If it's extremely complex, it's going to take a more complex [hand hygiene] program," he says.

The Accreditation Association for Ambulatory Health Care (AAAHC) requires that organizations adopt nationally recognized guidelines for handwashing, such as one from WHO, the CDC, the Association for Professionals in Infection Control and Epidemiology (APIC), or the Association of perioperative Registered Nurses (AORN).

"We don't care which one or which combination," says Jack Egnatinsky, MD, the immediate past chair of the AAAHC Board of Directors and one of two medical directors for AAAHC. Egnantinsky also performs surveys.

Once a program's leaders have adopted one set of guidelines, they must provide education and active surveillance, including in the area of hand hygiene, he says. Also, Medicare surveys have an infection control questionnaire, Egnatinsky points out. "They have a whole section that deals with hand hygiene," which supplements and complements the AAAHC standards, he says.

Also the AAAHC surgical services chapter requires organizations to have a written policy on appropriate and timely surgical hand antisepsis. Additionally, AAAHC surveyors follow patients from admission to the postoperative care unit (PACU). "Some of the observations we are looking for is to see if they are compliance with their organization's policy on hand disinfection," Egnatinsky says.

The growing interest of accreditation surveyors in infection control means a renewed focus by healthcare facilities, Bays says. Ten years ago, infection control used to be the job of one or two people, he says. "We've tried to expand it to everyone who comes in touch with patient care areas or patients themselves," Bays says.

Still, you need a leader, Bays says. "I see problems when there's not a champion or someone overlooking program," he says. "Otherwise, you may have audit, but it falls off and doesn't get reported to the committee." (See tips for improving compliance, below.)

Steps to help you improve compliance

If you find that your staff's hand hygiene compliance is less than stellar, drill down to try to identify where the problem is, suggests Richard Bays, RN, MBA, CPHQ, CLNC, of R Bays Consulting in Houston, TX.

"For example, are you lacking compliance in preop, postop, or the OR?" Bays says. "Or is the compliance problem with a level of employee, such as nursing"

The problem might be mechanical in nature, Bays says. "For example, if you have a wall-mounted antisepsis, it's sometimes not in a place convenient for actual practice," he says. "Instead, it is in a place where it was convenient to mount."

Talk to staff to determine the problem, he advises. You might find that a sink is broken, and members of the staff have to go to a different department to perform hand hygiene. An antisepsis dispenser might always be empty, or a sink might frequently be out of paper towels. "Those are things that can sink your program," Bays says.

If you want to improve hand hygiene performance and compliance, staff education is a key factor, says Kathleen Richmond, RN, MS, CIC, associate director of the Standards Interpretation Group, Division of Healthcare Improvement at The Joint Commission. (The Joint Commission offers a Targeted Solutions Tool [TST] for hand hygiene that can be found on The Joint Commission Center for Transforming Healthcare's website at

Consider these additional tips:

• Focus on hand sanitizers.

Provide antiseptic hand sanitizers on a wall and also distribute individual sanitizers to staff members to keep in their pockets, Bays suggests.

"When surveyors come out, you may be doing great job, but they have to see it to 'give you points,'" he says.

• Disinfect the hands after removing gloves.

Medicare standards says that even if staff members are performing hand hygiene and wearing gloves, they are expected to disinfect their hands after contact with blood and body fluids, says Jack Egnatinsky, MD, the immediate past chair of the Accreditation Association for Ambulatory Health Care (AAAHC) Board of Directors and one of two medical directors for AAAHC.

"People think when they're wearing gloves, that's all they have to do," Egnatinsky says. "But they can create environment for bacteria to grow rapidly with higher body temperature and higher humidity that comes with sweating in gloves. "

As a surveyor, this is the area where he has seen the greatest failure to comply with policies. "Physicians are usually the people who don't follow that," Egnatinsky says.

• Don't forget the physicians.

Physician compliance is a sticking point for many programs, Bays admits.

"Spend time with the doctors," he advises. "They tend to be forgetful, but once they get into the habit, it tends to stick."

Egnatinsky says to educate everyone, from aides and nurse assistants to nurses and physicians, "anybody at all that has any direct contact with patients or equipment used by patients. It's a simple thing to do, and it has such as positive impact on outcomes."