By Rommie Johnson, MPH, PMP
Accreditation surveys exist to strengthen organizations, not to catch them off guard. When ACHC surveyors identify areas for improvement, those findings become a roadmap for elevating patient safety and operational excellence.
ACHC’s latest analysis of surveys conducted between June 2024 and May 2025 highlights patterns worth examining – not as failures, but as opportunities. Understanding what surveyors observe most frequently gives your team a headstart on strengthening practices that protect patients and staff. Two infection prevention standards emerged as common areas where ASCs can focus their improvement efforts, before survey day arrives.
Building A Robust Infection Prevention Program
Approximately 29% of surveyed ASCs received findings related to infection control. The standard (05.00.02 Infection Prevention and Control Program Development) asks facilities to select nationally recognized guidelines, train staff consistently and maintain active surveillance. When gaps appear, they typically fall into three predictable categories.
1. Policy alignment. Surveyors sometimes discover that infection control policies and procedures haven’t kept pace with current requirements. Missing elements might include:
- State-level notifiable disease reporting procedures.
- Personnel screening protocols.
- Clear authority structures for managing staff health concerns.
A thorough policy audit can reveal these gaps before a surveyor does.
2. Training documentation. The intent behind training requirements is straightforward: Every team member should understand infection prevention principles and their role in maintaining a safe environment. When personnel files lack documentation of initial or annual training, it raises questions about whether that knowledge transfer actually occurred. Required training topics typically include:
- Hand hygiene and alcohol-based hand sanitizer use.
- Safe injection practices.
- Environmental cleaning and disinfection.
- Standard precautions.
- Bloodborne pathogen protocols.
Systematic file audits help ensure documentation reflects the training your team has completed.
3. Practice consistency. Perhaps the most valuable survey observations involve real-time practices. Surveyors have noted instances where staff members exchanged gloves without performing hand hygiene between changes – a deviation from both policy and best practice. These observations aren’t meant to penalize. They’re meant to surface behaviors that training and reinforcement can address.
Proactive Steps for Your Team
- Anchor your program in recognized guidelines. Whether your facility draws from AORN, APIC, CDC, SHEA or another source, that framework should be documented and visible throughout your policies.
- Audit personnel files with fresh eyes. Select a representative sample and verify that training documentation exists for each required topic. Treat gaps as an opportunity to strengthen onboarding and annual education processes.
- Put monitoring data to work. If hand hygiene observations reveal inconsistencies, develop targeted training that addresses specific behaviors. Focused interventions tied to actual observations make a bigger difference than generic refreshers.
Maintaining A Sanitary Environment Under Daily Pressure
Environmental sanitation findings appeared on 43% of surveys – making it the most frequently cited infection prevention standard (05.00.06 Sanitary Environment). Unlike documentation reviews, these findings stem entirely from direct observation. That’s actually encouraging news: What surveyors can see, your team can see, too.
The physical environment of a busy ASC experiences constant stress. Equipment ages. Surfaces accumulate dust. High-touch areas show wear. The challenge lies in maintaining vigilance amid the pressure of daily operations.
Surveyor observations from the past year illustrate common environmental concerns:
- Dust accumulation on air vents and equipment surfaces.
- Floors with visible soil or inadequate cleaning.
- Fixtures in need of repair (detached faucets, non-functioning toilets).
- Storage practices that expose supplies to contamination.
- Rust on IV poles, tables, carts and casters.
- Debris from previous procedures remaining in ORs after turnover.
One observation captures a tension navigated by many ASCs. The push for efficient OR turnover can sometimes overshadow thorough between-case cleaning. Surveyors have noted that actual cleaning practices did not match written protocols, for example, dry mopping replacing the required damp mopping with disinfectant.
These aren’t “gotcha” moments. They’re insights into where operational pressures create risk, and where additional attention can make a meaningful difference.
Creating Eyes Everywhere
Environmental awareness works best as a shared responsibility. When every team member feels empowered to identify and report concerns, issues are addressed promptly. Consider these strategies:
- Implement structured surveillance rounds. Regular walkthroughs focused specifically on environmental conditions help facilities stay ahead of accumulating issues. Engage all staff – not just housekeeping or infection preventionists – in observation-based rounding.
- Audit room turnover practices. Review between-case cleaning protocols and observe whether actual practice aligns with documented expectations. If policies specify damp mopping with appropriate contact time for disinfectants, verify that’s what happens when the clock is ticking.
- Build observational skills through training. “Spot the improvement opportunity” exercises during staff meetings sharpen awareness and reinforce that environmental quality belongs to everyone.
- Create clear reporting pathways. A chipped surface, a malfunctioning fixture and dust on equipment are observations that should flow naturally into work orders and timely resolution.
Partnering For Excellence
The patterns revealed in this year’s data confirm something experienced leaders already understand. Most findings trace back to gaps between intention and execution. Policies exist but weren’t fully implemented. Training occurred but wasn’t documented. Cleaning protocols were established but adapted under time pressure.
Accreditation surveys bring outside eyes that can see what daily familiarity sometimes obscures. ACHC’s role isn’t to identify problems and criticize organizations. Our role is to help identify opportunities for strengthening the practices that keep patients safe.
To support that journey, ACHC offers resources at every stage:
- Expert guidance on common compliance challenges at https://achc.org/articles/cat_-ambulatory-surgery-center/
- Free educational webinars and tools at achcu.com/ambulatory-surgery-center-webinars/.
Your preparation starts now. ACHC is here to help.
Rommie Johnson, MPH, PMP, is program director for ambulatory surgery centers and office-based surgery settings at Accreditation Commission for Health Care (ACHC), where he leads a team of talented staff and surveyors.
