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AAHC UPDATE: Relating Your QI Program to Infection Prevention

In last month’s OR Today, you learned about QI resources from Dr. Naomi Kuznets, the Director of AAAHC’s Institute for Quality Improvement. Now I’d like to help you tie your quality improvement program directly to your infection prevention efforts and share a few things I’ve learned while working with AAAHC accredited organizations.

Use your QI program to lobby for your IP needs
In 2009, the Centers for Medicare and Medicaid Services published a survey protocol, Conditions for Coverage (CfC), and the companion Interpretive Guidelines, the first updates to these documents in several years. It seems impossible that almost three years has elapsed since these major changes became effective, doesn’t it? The impact on ASCs was significant, as there were many new topics previously not present in the Medicare requirements. One of the most important topics was the newly stated relationship between quality improvement and infection prevention. This is an imperative for all healthcare settings including Medicare certified ambulatory surgery centers.

By now you’ve undoubtedly married your formal Infection Control program (CfC 416.51) with your written Quality Assessment and Performance Improvement program (CfC 416.43). Have you chosen performance improvement activities that focus on your higher volume, higher risk areas? Do those activities allow your organization to improve patient safety, quality of care and patients’ health outcomes? If you’ve chosen activities designed to help make your organization “look good,” instead of activities that will actually improve your care, adjust your priorities now.

Know your applicable local, state and federal requirements
It’s an organization’s responsibility to remain cognizant of and abide by all applicable local, state and federal laws and regulations. Here are suggestions for being “in the know” about state laws that may trump some of Medicare’s own requirements:

1. Become active at the state or national level in a professional society such as the Ambulatory Surgery Center Association, Most professional societies have a section devoted to legislative actions listed by state.

2. Stay in touch with your state legislators. Subscribe to blogs or frequently visit your state’s Senate and House of Representatives websites, especially when you’re aware of health care legislation that seems to be moving forward. Because such legislation impacts your business, I suggest marking your own calendar to make a monthly visit to these websites or, if possible, drop into the local area office of your state representative.

3. Request that your Governing Body consider delegating to your general legal counsel the responsibility of monitoring legislative actions that impact your organization.

4. If one or more of your ASC providers have local area hospital medical staff privileges, updates that include outpatient care might be available through the hospital.

Remember that it’s your organization’s responsibility to remain current on and abide by all applicable laws and regulations.

Tap Into Resources – Most Are F-R-E-E
OK, there’s a whole lot of information out there – some of it valuable, some of it not. Finding the time to sort through resources could become a never-ending assignment. Here are hints to help you get organized:

AAAHC Standards and Medicare Conditions for Coverage both require actions toward mitigation of health care-acquired infections. For example, compliance with hand hygiene protocol should be on your organization’s list of monitored activities. Your organization’s hand hygiene policy will reflect your chosen hand hygiene guidelines – CDC, WHO or other nationally recognized guidelines. How will you ensure that your chosen guideline hasn’t been updated since it was first chosen?

1. Save the guideline website in your browser “Favorites” for easy future access and sign up for “Alerts” from that website
2. Delegate the annual verification of the most-recent version of your chosen guideline to a clerical staff member
3. Review (and update, when indicated) your organization’s formal hand hygiene policy
4. Indicate (where?) the date the guideline was verified as being most current version, and the date of the policy review
5. Make certain – annually and as needed – that the Governing Body’s review of the Infection Control program is mentioned in its formal minutes, and that the internal education agenda includes review of that hand hygiene policy. Repeat points 1 through 5 for other policies relying on nationally recognized guidelines. But you aren’t done yet!

Keep the IP dialogue going at every opportunity
In order to provide a safe and sanitary environment for your patients, use every opportunity to promote your infection prevention focus. This works best if you find ways to make infection prevention pertinent as well as interesting and fun. There are many excellent infection prevention videos from basic to very complex (hint: Google “Do It in Your Sleeve” video). Search the web and Facebook and choose the videos and teaching tools most applicable to your organization’s services and needs. Add the video or tool to your requirements for new employee orientation and to your annual staff education agenda. Have new employees and their mentors watch videos together if possible. No way to view the video at your organization? Then make it an at-home assignment. Create a list of twenty questions based on the video, and rotate three or four of those questions for use as preand post-video measurement of viewer’s knowledge. Use the compiled post-test responses to inform your annual or as-needed staff education opportunities.

All – repeat all – staff should be involved in your infection prevention program. Make attainment of your program goals part of everyone’s written job description. Identify your infection prevention champions irrespective of their employment roles, and engage them in recruitment of their peers. For example, engage and empower that great environmental services employee to get peers on board with staff awareness and correcting deficiencies. Train every single employee in your hand hygiene protocol, then rotate the task of monitoring compliance with the protocol to every single one of them. Find small ways to reward staff members who comply.

Consider making your patients aware of your infection prevention program too. For example, you might inform your patients of the importance of hand hygiene for themselves and others, including the hand hygiene performed by your staff during their visit. I’ve seen clever implementation of patient involvement in monitoring for staff hand hygiene. Check out a newly released and FREE program that includes posters, brochures and wallet cards to reduce HAI, and aimed at patients and families at

Infection prevention is everyone’s responsibility. Make infection prevention part of every decision, every patient contact, every day!

Marsha Wallander is an Assistant Director, AAAHC Accreditation Services. She also represents AAAHC on the CDC Foundation Safe Injection Practices Coalition (SIPC) of which AAAHC is a founding member. Please visit for safe injection information.



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