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Meeting CMS Requirements for Infection Prevention in Ambulatory Surgery Centers


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Title: Meeting CMS Requirements for Infection Prevention in Ambulatory Surgery Centers

Meeting CMS Requirements for Infection Prevention
in Ambulatory Surgery Centers
  • September 18, 2012
  • APIC Badger Chapter
  • Madison, WI
  • Presenter
  • Judy Hintzman RN MS CIC

  • Understand the elements of infection prevention
    and control in ambulatory settings surveyed by
  • Describe how to perform a facility risk
  • Identify the initial steps in implementing change
    in your organization.

Centers for Medicare and Medicaid Services (CMS)
  • Federal agency that administers
  • Medicare and Medicaid
  • Enforces federal quality standards for various
    healthcare settings
  • Maintains oversight of ASCs, long term care
    facilities, home health agencies, intermediate
    care facilities, mental health facilities and
  • Administers Quality Improvement Organizations at
    state level

What Led to the Focus on Infection Control in
  • Cluster of Hepatitis C virus infections (Nevada)
    related to endoscopy procedures
  • Survey of that ASC identified unsafe injection
    practices resulting in 40,000 patients notified
    of potential exposure.
  • Nevada also identified other ASCs with deficient
    infection control practices.
  • CDC has reported other outbreaks related to
    bloodborne infectious diseases in other states.

CMS Conditions for CoverageInfection Control
Requirements 5/18/09
  • 416.51 Infection Control The ASC must maintain an
    infection control program that seeks to minimize
    infections and communicable diseases.
  • Standard A Sanitary Environment The ASC must
    provide a functional and sanitary environment for
    the provision of surgical services by adhering to
    professionally acceptable standards of practice.

CMS Conditions for CoverageInfection Control
Requirements 5/18/09
  • Standard B Infection control program. The ASC
    must maintain an ongoing program designed to
    prevent, control, and investigate infections and
    communicable diseases. In addition, the
    infection control and prevention program must
    include documentation that the ASC has
    considered, selected, and implemented nationally
    recognized infection control guidelines.

CMS Conditions for CoverageInfection Control
Requirements 5/18/09
  • The program is
  • (1) Under the direction of a designated and
    qualified professional who has training in
    infection control
  • (2) An integral part of the ASCs quality
    assessment and performance improvement program

CMS Conditions for CoverageInfection Control
Requirements 5/18/09
  • The program Is
  • (3) Responsible for providing a plan of
    action for preventing, identifying, and managing
    infections and communicable diseases and for
    immediately implementing corrective and
    preventive measures that result in improvement.

What is an Ambulatory Surgical Center or ASC (per
  • Any entity that operates exclusively for the
    purpose of providing surgical services to
    patients not requiring hospitalization
  • Duration of services not expected to exceed 24

What is Surgery per CMS?
  • Procedure performed for purpose of structurally
    altering the human body by incision or
    destruction of tissues.
  • Diagnostic or therapeutic treatment of conditions
    or disease processes by any instruments causing
    localized alteration or transposition of live
    human tissue which includes lasers, ultrasound,
    ionizing radiation, scalpels, probes and needles.
    Endoscopy is included in definition.
  • Injections of substances into body cavities,
    internal organs, joints, sensory organs, and the
    central nervous system.

The ASC Survey Process for CMS
  • Certification accomplished through
  • Observations and tours
  • Interviews
  • Document and record reviews

Survey ProcessNo more drive by CMS surveys
October 2009 - first training in 10 years
  • Focus on staff that do procedures
  • Case tracer methodology
  • Surveyors required to follow at least one patient
    from admission, through surgery and recovery, to
  • Infection control surveyor worksheet is used to
    collect information (16 pages)

Accreditation StandardsMust be met to receive
  • Government regulations- CMS - OSHA
  • ASC accrediting agencies
  • AAAHC Accreditation Association for Ambulatory
    Health Care
  • AAAASF American Association for Accreditation for
    Ambulatory Surgery Facilities
  • AOA American Osteopathic Association
  • Best practices may become standard of care
  • Guidance documents
  • Environmental Infection control
  • Terminal cleaning of OR room
  • Prevention of Surgical Site Infection
  • Have you read CDC document?
  • How is information shared when SSIs are
  • Hand Hygiene
  • Have you read the CDC document?
  • Have you done observation studies on compliance?

Infection Prevention Program Required Elements
  • Written plan
  • Risk assessment
  • Qualified licensed professional to direct the
  • Education in Infection Prevention is documented
  • Can be certified but not required
  • Selection of nationally recognized guidelines
  • Available to staff and current
  • Evidence of compliance with guidelines
  • Surveillance system including notifiable disease
    reporting to State
  • Staff education and training
  • Must have an annual plan
  • Documented training

CMS ASCInfection Control Worksheet (ICWS)
  • Initial tool developed by CDC as part of Nevada
    Outbreak investigation
  • 10 million funding made it possible to increase
    ASCs surveys and implement process nation wide
  • Some accreditation organizations are also using
    the ICWS
  • Original goal collect ICWS from 1500 ASCs

CMS Survey Outcomes
  • No Deficiency
  • Standard Level
  • Condition Level
  • Immediate Jeopardy

Focus on Specific Infection Prevention Practices
  • Hand Hygiene (including glove use)
  • Safe injection practices (including use of
    medication vials)
  • Disinfection and sterilization
  • Environmental infection control
  • Safe use and handling of point of care devices

ASCs Characteristics Sample Questions
  • 1) ASC name
  • 2) Address
  • 3) 10-digit CMS Certification Number
  • 4) What year did the ASC open for operation?

ASCs Characteristics Sample Questions
  • What is the primary procedure performed at the
    ASC (i.e., what procedure type reflects the
    majority of procedures performed at the ASC).
    Check only ONE
  • ? Dental ? Orthopedic
  • ? Endoscopy ? Pain
  • ? Ear/Nose/Throat ? Plastic/reconstructive
  • ? OB/GYN ? Podiatry
  • ? Ophthalmologic ? Other

ASCs Characteristics Sample Questions
  • What additional procedures are performed at the
    ASC (Check all that apply)?
  • ? Dental ? Orthopedic
  • ? Endoscopy ? Pain
  • ? Ear/Nose/Throat ? Plastic/reconstructi
  • ? OB/GYN ? Podiatry
  • ? Ophthalmologic ? Other ____________

ASCs Characteristics Sample Questions
  • Who does the ASC perform procedures on? (Check
    only ONE)
  • ? Pediatric patients only
  • ? Adult patients only
  • ? Both pediatric and adult patients

ASCs Characteristics Sample Questions
  • What is the average number of procedures
    performed at the ASC per month?
  • How many Operating Rooms (including procedure
    rooms) does the ASC have?
  • of rooms
  • actively maintained

ASCs Characteristics Sample Questions
  • Please indicate how the following services are
    provided (check all that apply)
  • Anesthesia ?Contract ? Employee ? Other____
  • Environmental Cleaning ?Contract ? Employee ?
    Other ____
  • Linen ?Contract ? Employee ? Other ____
  • Nursing ?Contract ? Employee ? Other ____
  • Pharmacy ?Contract ? Employee ? Other ____
  • Sterilization/Reprocessing ?Contract ? Employee
    ? Other ____
  • Waste Management ?Contract ? Employee ? Other

Worksheet Standard Assessment
  • Does the ASC have an explicit infection control
    program? ? YES ? NO
  • NOTE! If the ASC does not have an explicit
    infection control program, a condition-level
    deficiency related to 42 CFR 416.51 must be

Worksheet Standard Assessment
  • Does the ASCs infection control program follow
    nationally recognized infection control
  • ? YES ? NO
  • NOTE! If the ASC does not follow nationally
    recognized infection control guidelines, a
    deficiency related to 42 CFR 416.51(b) must be
    cited. Depending on the scope of the lack of
    compliance with national guidelines, a
    condition-level citation may also be appropriate.

Worksheet Standard Assessment
  • Is there documentation that the ASC considered
    and selected nationally-recognized infection
    control guidelines for its program?
  • ? YES ? NO

Worksheet Standard Assessment
  • Which nationally-recognized infection control
    guidelines has the ASC selected for its program
    (Check all that apply)?
  • NOTE! If the ASC cannot document that it
    considered and selected specific guidelines for
    use in its infection control program, a
    deficiency related to 42 CFR 416.51(b) must be
    cited. This is the case even if the ASCs
    infection control practices comply with generally
    accepted standards of practice/national
    guidelines. If the ASC neither selected any
    nationally recognized guidelines nor complies
    with generally accepted infection control
    standards of practice, then the ASC should be
    cited for a condition-level deficiency related to
    42 CFR 416.51

Worksheet Standard Assessment
  • Does the ASC have a licensed health care
    professional qualified through training in
    infection control and designated to direct the
    ASCs infection control program?
  • ? YES ? NO
  • is this person an (check only ONE)
  • ? ASC employee
  • ? ASC contractor

Worksheet Standard Assessment
  • Is this person certified in infection control
    (i.e., CIC)
  • (Note 416.50(b)(1) does not require that the
    individual be certified in infection control.)
  • ? YES ? NO
  • If this person is NOT certified in infection
    control, what type of infection control training
    has this person received?

Worksheet Standard Assessment
  • On average how many hours per week does this
    person spend in the ASC directing the infection
    control program?
  • Note 416.51(b)(1) does not specify the amount
    of time the person must spend in the ASC
    directing the infection control program, but it
    is expected that the designated individual spends
    sufficient time directing the program, taking
    into consideration the size of the ASC and the
    volume of its surgical activity.)

How Many IC Hours per Week?
  • Does not specify
  • The amount of time needed to direct the program
    is relative to the size and scope of service
  • Judys thoughts - at least 3 times a week- 4
    hours per day until the program is established.
    There is lots to do!

Worksheet Standard Assessment
  • Does the ASC have a system to actively identify
    infections that may have been related to
    procedures performed at the ASC? ? YES ? NO
  • If YES, how does the ASC obtain this
  • Sends e-mails to patients' after discharge.
  • Follows up with patients primary provider after
  • Relies on the surgeon at a follow up visit to
  • Other

Worksheet Standard Assessment
  • Is there supporting documentation confirming this
    tracking activity?
  • ? YES ? NO

Worksheet Standard Assessment
  • Does the ASC have a policy/procedure in place to
    comply with State notifiable disease reporting
  • ? YES ? NO

Worksheet Standard Assessment
  • Do staff members receive infection control
  • ? YES ? NO
  • If YES,
  • How do they receive infection control training
    (check all that apply)?
  • ? In-service
  • ? Computer-based training
  • ? Other (specify)

Worksheet Standard Assessment
  • Which staff members receive infection control
    training? (check all that apply)
  • ? Medical staff
  • ? Nursing staff
  • ? Other staff providing direct patient care
  • Staff responsible for on-site sterilization/high-
  • level disinfection
  • ? Cleaning staff
  • ? Other (specify)

Worksheet Standard Assessment
  • Is training
  • The same for all categories of staff ?
  • Different for different categories of staff ?

Worksheet Standard Assessment
  • Indicate frequency of staff infection control
    training (check all that apply)
  • ? Upon hire
  • ? Annually
  • ? Periodically/as needed
  • Other (specify)

Survey Process
  • Tracer methodology
  • Focus on staff who perform procedures
  • Injection practices nurses physicians
  • Instrument reprocessing reprocessing

Hand Hygiene
  • Challenging to assess
  • Observations in patient-care areas
  • Pre-operative area
  • Post-operative area
  • Focus on
  • Nurses
  • Physicians

Hand Hygiene
  • Soap and water available
  • Alcohol-based hand rubs available and installed
    as required
  • Staff perform hand hygiene correctly
  • After removing gloves
  • After direct patient contact
  • Before performing invasive procedure

Glove Use
  • Healthcare providers should wear (non-sterile)
  • For procedures that might involve contact with
    blood or body fluids
  • When handling potentially contaminated patient
  • Healthcare providers should remove gloves (and
    immediately perform hand hygiene) before moving
    to the next task and/or patient

Gloves Common Mistakes Seen
  • Failure to clean hands after gloves removed.
  • Moving from patient to patient without cleaning
    hands and changing gloves
  • Using alcohol based hand rub on gloves
  • Thinking double gloving protects against puncture
  • Not having gloves accessible in locations where
    they are needed/ and used.

Injection SafetyInjectable medications, saline,
other infusates
  • Observations in patient care and medication
    preparation areas
  • Pre-operative area
  • Operating/Procedure rooms
  • Anesthesia cart
  • Focus on
  • Nurses (e.g., RN, CRNA)
  • Physicians (e.g., anesthesiologists)

Injection Practices
Injection Safety
  • Needles are used for only one patient
  • Syringes are used for only one patient
  • Medication vials are always entered with
  • New needle
  • New syringe

Handling of Single-dose Medications and Supplies
  • Single-dose medication vials
  • Manufacturer-prefilled syringes
  • Bags of IV solution
  • Medication administration tubing and connectors

Handling of Multi-dose Medications
  • Rubber diaphragm is disinfected with alcohol
  • prior to each entry.
  • Vials are dated when opened and discarded within
    28 days or according to manufacturer
    instructions, whichever comes first
  • Vials are not stored or accessed in the immediate
    areas where direct patient contact occurs (e.g.,
    at patient bedside)

Label Requirements are Strictly Enforced
  • Medications that are pre drawn are labeled with
    the time of draw, initials of the person drawing,
    medication name, strength and expiration date or
  • There are NO acceptable work arounds or
    substitute practices to avoid using a label.

Inspection Of Multi-Dose VialsNeed a policy and
assure practice
  • Multi-dose vials used on gt1 patient
  • Vial septum disinfected with alcohol before entry
  • New needle and syringe for each access
  • Vials are dated when opened and discarded in 28
    days or manufacturers expiration date, which
    ever comes first.
  • Reminder single dose and multi-dose vials are
    not interchangeable.
  • Drug cost/availability does not justify doing so.

Surveyors will look in more than one place for
injection safety deficiencies
  • Important Reminders
  • Per CDC, medications should be drawn up as close
    to the point of use as possible
  • Do not carry over pre drawn syringes from one
    day to the next, discard at the end of the day.
  • Do not spike your IV bags and sets before they
    will be used
  • NEVER use a bag of saline to pre fill syringes
  • NEVER combine the leftover contents in
    partially used vials.

A frequently asked question.Do CMS and CDC
permit incremental dosing? YES but only when
  • Same syringe, same drug
  • Required intra-operatively
  • No opportunity to reuse with another patient
  • Anesthesia most common scenario

  • Pre cleaned
  • Visually inspected
  • Chemical indicator is used
  • Biologic indicator is performed at least weekly
  • Documentation for each sterilizer is maintained
    and up to date and includes results from each load

Flash Sterilization Update
  • Past Definition very short cycle for small and
    unwrapped load.
  • Sterilization of unwrapped/uncontained loads
    should be used for urgent and unpredicted need
    (e.g. dropped instrument).
  • Routine sterilization of unwrapped/uncontained
    loads is inappropriate and will be cited as a
    violation by CMS.

Short Sterilization Cycle (Flash Sterilization)
  • Short sterilization cycle of wrapped/contained
    load is OK
  • Requirements
  • Sterilizers cleared by FDA to run short cycles
  • Validated by manufacturers to perform
    effectively in those cycles for defined
    validation loads.

Short Sterilization CycleSurveyor will ask these
  • Is sterilizer labeled for this cycle by
  • What is the manufacturer-recommended load for
    that cycle?
  • Is the containment device used labeled by
    manufacturer for use in that cycle?
  • For what load is the containment device
    recommended by its manufacturer?
  • Is the chemical indicator (and biological if
    used) labeled for use for this cycle by the
  • If the cycle is used frequently, is it checked
    regularly with a biological indicator?

Short Sterilization Cycle
  • Factors to consider that will influence outcome
  • Weight and complexity of materials in the load
  • Presence or absence of fabric in load
  • Presence or absence of lumens

Short Sterilization Cycle
  • If manufacturers instructions are not followed ,
    then the outcome of the sterilizer cycle is
    guesswork, and the ASCs practices will be cited
    as a violation.
  • Surveyors will also observe whether adequate pre
    cleaning is being performed with water and
    detergent or water and enzymatic cleaners.

High Level Disinfection
  • Semi critical equipment is high level disinfected
    or sterilized
  • Items are pre cleaned and visually inspected
  • Equipment is maintained
  • Chemicals are prepared, tested and replaced
    according to manufacturers recommendations.
  • Items are allowed to dry before use
  • Items are stored in designated clean area

JCAHOGuidance on Laryngoscope Blades
  • Per CDC Laryngoscope blades are semi critical
    items. They should be sterilized or high level
    disinfected before reuse.
  • Stored in a way to prevent recontamination.
  • Examples of non compliant storage
  • Unwrapped blades in an anesthesia drawer or top
    of a code cart
  • Examples of compliant storage
  • Peel pack (long term)
  • Wrapping in sterile towel (short term)

JCAHOGuidance on Laryngoscope Blades
  • Laryngoscope handles must be processed prior to
    use on next patient.
  • Follow manufacturers recommendations
  • Low level disinfectant on surface of handle
  • Check with state for additional law or

Environmental Infection Control
Point of Care Devices
  • Observation in
  • Pre-operative area
  • Post-operative area
  • Focus on
  • Nurses

Glucose TestingFinger stick Devices
  • A new single-use, auto-disabling lancing device
    is used for each patient

Glucose TestingFingerstick Devices
  • Lancing penlet devices should NOT be used for
    multiple patients

Point of Care Devices
  • Glucometer is not used on more than one patient
    unless manufacturers instructions indicate this
    is permissible
  • Glucometer is cleaned and disinfected after every

CMS Visits To Date in Wisconsin
  • 9/1/11- 8/31/12
  • 30 surveys
  • 1/1/12-8/31/12
  • 19 surveys

Problem Prone AreasSanitary Environment- must
provide a sanitary environment by following
professionally acceptable standards of practice.
  • Floors not clean
  • Food prepared next to hand washing sinks and
    sharps containers
  • Refrigerator/freezer temps not monitored
  • Walls chipped
  • Wet OR floors with blood/body fluids tracked
    outside OR suites

Problem Prone AreasInfection Control Program
  • ASC has not decided on what nationally recognized
    standards will be followed.
  • Hand washing/gloving by all staff
  • Eye shields not worn in surgery
  • Leaving the OR, going outside, reentering the OR
    without changing scrubs.
  • Using glucose meters not for multiple patient use
  • Enzymatic cleaner and water concentrations not
    measured per manufactures directions.

Problem Prone AreasInfection Control Program
  • Sterile field broken-back to instrument table
  • Staff not screened for infections and
    communicable diseases (TB, Rubella, Hepatitis)
  • Recapping of needles two handed
  • Oxygen tubing ready to use open to air
  • CSS door propped open to hallways
  • Boxes of patient supplies stored on floors

Problem Prone AreasInfection Control Program
  • Flash sterilization used daily/frequently due to
    lack of appropriate number of instrument trays
  • Lack of infection control program and active
  • Using hand sanitizers on gloved hands
  • Cross contamination between clean and dirty

Problem Prone AreasProgram under direction of a
qualified professional
  • No one assigned by governing body who will lead
    the ASC IC program
  • Not qualified
  • Not enough time dedicated to do the job
  • No training or on going education

Problem Prone AreasIC Director is responsible
for plan of action for preventing, identifying,
and managing infections and for implementing
corrective/preventive measures that result in
  • ASC does not have active surveillance to ensure a
    sanitary environment and staff adherence to IC
    policies and current standards of practice
  • Anesthesia/medical staff not included as part of
    active surveillance
  • Not assessing the risks of type of procedures
    performed and type of staff who work in ASC
  • Collection of data without analysis and action
    plans related to post op infections
  • Does not have PP related to disease reporting to
    health departments.

Problem Prone Area The IC program is an integral
part of the ASCs quality assessment and
performance improvement program
  • The ASC does not include measure/indicators and
    activities to IC into the QAPI program which
    governs all their patients
  • No evidence that IC activities result in actions
    designed to improve IC within the ASC
  • Judys passion is to show that all of our hard
    work actually improved patient care!

Elements of the Infection Surveillance,
Prevention Control Program
  • Written Infection Prevention Control Plan
  • Risk Assessment
  • Authority statement
  • IC Service Description
  • Surveillance Plan
  • Goals Objectives
  • Prevention Control Strategies
  • Communications Reporting
  • Emergency Management Planning
  • Education
  • Evaluation of Program Effectiveness

Facility Risk AssessmentShould be done annually
  • Provides a basis for IP activities/annual
    surveillance plan
  • What populations do you serve?
  • What communicable diseases are in the community?
  • TB risk assessment must be done annually.
  • Identify high risk populations in your facility
  • High volume, high risk, or problem prone
  • Assist in focusing surveillance efforts
  • Meet regulatory requirements
  • Example OSHA requires biohazard waste to be
    contained and labeled correctly.

Facility Risk Assessment
  • Introduction
  • Identify who developed the document with
    collaboration from other team members (list)
  • Geographic location/ community environment/
  • List counties, community issues and patients
  • Care, treatment and services provided
  • Describe physical plant (ORs, Endo, procedures

Facility Risk Assessment cont.
  • List characteristics that increase risk
  • High volume cases, high risk procedures, implants
  • Community outbreaks
  • Resistant bacteria
  • Identify any area that needs to be improved.
  • List characteristics that decrease risk
  • Education of staff to prevent infection
  • Identify improvements/implementations
  • Increased hand hygiene compliance
  • Use of PPE especially gloves
  • Follow CDC guidelines to prevent SSI
  • Timing of antibiotics
  • No razors

Resources Facility Risk Assessment
  • Beckers ASC Review _at_
  • Using an Infection Control Risk Assessment to
    Create an Infection Control Plan _at_
  • Association of Wisconsin Surgery Centers, Inc.
    (WISCA) Course scheduled December 2012 _at_

Facility TB Risk Assessment
  • Risk assessment form specific for ambulatory
  • APIC Infection Prevention Manual for Ambulatory
    Care 2009 Section 9.
  • Follow State Law
  • Screen everyone on hire
  • Medium risk annual screening
  • Low risk no additional screening unless exposure

Authority Statement Must be Written
  • The Board of Directors (Medical Director/Quality
    Committee) authorizes and supports the Director
    (Manager/etc.) of Infection Prevention to
    institute appropriate infection control measures
    within the facility. This includes authority to
    employ whatever methods necessary when, in their
    judgment, there is reasonable possibility of
    immediate danger to any patient's), personnel or
    others in the facility.

Surveillance PlanShould be done annually
  • How surveillance methodology
  • How will data be collected?
  • What indicators and events will be counted?
  • Outcome monitors
  • Surgical site Infections
  • Process monitors
  • Hand Hygiene rate
  • Influenza immunization rates
  • Terminal cleaning done correctly
  • Why reduce risk improve patient care
  • Comparative databases should be used
  • Outbreak identification and response should be

Healthcare Associated Surgical Site Infections
  • Definition of SSI should be written and utilized-
    provide definitions to surgeons.
  • Surveillance system must be in place to identify
    and evaluate every infection
  • Develop a process for case finding (patient
    education should include signs and symptoms to
    look for and emphasize infection prevention
  • Record variables for every procedure being
    monitored (surgical wound class, ASA
    classification, duration of operation)
  • Report SSI info to the surgical team on a routine
    basis (quarterly) and as each case occurs.

Healthcare Associated Surgical Site Infections
  • Data collection should include
  • Basic demographics (name, MR number, age, gender,
    date of procedure)
  • Infection information (date of onset, site of
    infection, microorganisms)
  • Clinical information ( signs and symptoms
  • Laboratory information (date of culture, result)
  • Antibiotic therapy (preop, therapeutic)
  • Surgery information (date, start and stop times,
    surgeon, wound classification, and severity of
    illness ASA score )
  • Procedure information (type, date)
  • Predisposing factors( (diabetes, steroids, skin

Use Nationally Recognized Guidelines to Reduce
Risk of Surgery-Related Infections
  • Antibiotics administered right time, right
    antibiotic and discontinued appropriately after
  • Aseptic technique
  • Blood sugar control
  • Pre op showers
  • No shaving whenever possible
  • No razors!

Implementing Change in your Organization
  • First Steps
  • Conduct your risk assessment
  • Prioritize the needs of your organization

Implementing Change in your Organization
  • Do not try to fix everything all at once.
  • Make a list of available resources you already
  • Identify what you do already?
  • Identify a champion who can help.
  • Identify small group of influential leaders
    committed to patient safety who can help
  • Develop a plan of action (1-2 years)

Advice from Judy
  • Meet with leadership-get support ASAP
  • Identify the amount of time needed to accomplish
    all that must be done- stick to it!
  • Create a plan of action ( 3 month , 6 month, 12
  • Join APIC chapter
  • Obtain necessary references to do the job
  • Infection Control in Ambulatory Care 2004
  • Infection Prevention Manual for Ambulatory care
  • Develop a Facility Risk Assessment ASAP
  • Develop a Surveillance Plan ASAP

What Are Some Barriers To Change?
  • Unexpected changes in external conditions
  • A lack of commitment in implementation
  • Resistance of people involved
  • Lack of resources
  • Conflicting goals or priorities

How Can You Make Change Happen?
  • Before implementing change, you need to convince
    people that change is needed
  • Never, never underestimate the power of

Skills Needed to Lead Change
  • Commitment to the plan
  • Realistic goal setting
  • Communication skills
  • Flexibility
  • Ability to stimulate motivation in others
  • Follow through

  • The CMS regulations are a golden opportunity to
    improve patient safety in the ambulatory surgery
    setting, as well as employee safety.
  • The emphasis on medication and injection safety
    and processing instruments and scopes is
  • This work will make a difference!

  • Thank You!
  • Judy Hintzman RN MS CIC Infection Preventionist
  • 262-408-8130
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