Beers says. “It consists of the infec- tion prevention nurse, medical direc- tor and me as the clinical director.” During QAPI meetings, the com- mittee develops auditing tools to see if the ASC has any compliance gaps. It also creates new policies to meet current recommendations from the Centers for Disease Control and Prevention, the ASC’s accreditation organization and the Association of periOperative Registered Nurses. Esser-Lipp says her ASC relies

heavily on checklists so no assigned infection prevention task is missed. “I have a large checklist manifesto that covers national and accreditation requirements. My infection control coordinator has designed checklists for her daily, weekly, monthly and annual responsibilities.” Although individuals might have specific roles to fill, infection pre- vention oversight is ultimately the responsibility of an ASC's govern- ing board, Yoder says. “The key is to show that infection control is a cen- ter-wide effort from the front line to the governing board. All must under- stand the process. Accreditors will expect to see that infection control as well as the role of the infection pre- ventionist and validation of trends and peer review data for recredential- ing purposes are mentioned in medi- cal executive and board minutes.”

Teamwork and Communication Drive Success When infection prevention responsi- bilities are spread out among multiple team members, effective coordination becomes pivotal, Yoder says. “If there is confusion about who is supposed to complete what task, this increases the likelihood of something being missed. That can lead to safety risks for patients and challenges with maintain- ing accreditation.” ASCs should cre- ate a workplan that will help everyone involved in infection prevention under- stand who is doing what, how they are

teaching with anesthesia and audited again,” Beers

says. “The cycle of

doing it and when they will be report- ing information on their responsibili- ties, she recommends. At The Surgery Center, frequent communication about infection pre- vention responsibilities between staff helps keep the ASC on track, Esser- Lipp

says. “Much of this occurs

through emails or conversations in the hallway, but then we dive into these discussions during scheduled meet- ings. Infection prevention is always part of our quality assurance meetings, which occur every other month, and our weekly management meetings.” During weekly meetings, Esser- Lipp says, managers discuss any infec- tion prevention-related matters that were brought to their attention. “When an issue is raised, we determine who on the management team will be responsible for ensuring it is addressed by the infection control coordinator or another staff member.” If a shortcoming is discovered at Pinnacle Surgery Center, the QAPI team comes together to address the challenge. For instance, an audit at the center looked into alcohol swab- bing the catheter hub prior to injec- tion

of medication and the study

revealed a lack of adherence with the anesthesiologists. “So we did some

teach, audit and post results contin- ues until we reach our goal. When there are issues with surgeons or anesthesiologists, we have our board speak with them so the conversation that occurs is peer to peer.” Much of the collaboration around infection prevention at The Surgery Center occurs within the facility, but Esser-Lipp says she also takes advantage of networking opportuni- ties at meetings and monitoring and participating in discussions on ASCA Connect. “I have benefitted greatly from the insight of other ASC profes- sionals who are kind enough to share recommended practices that help us improve our performance.”

Ongoing Support Is Essential If your ASC grows, be cognizant of how much additional work you are assigning to staff, Yoder says. “If you are in a busy center and everybody with infection prevention responsi- bilities is stretched too thin, you may need to review needs and increase your full-time equivalent (FTE) to meet demands. If staff are stretched too thin because they are wearing so many hats, you cannot expect them to complete their work appropriately. It can be a hard concept for govern- ing boards to allow more FTEs for this work, but this will help keep the ASC out of trouble.” Whether your ASC relies upon one team member or several to com- plete infection prevention responsibili- ties, helping these individuals succeed in their roles is paramount, Esser- Lipp says. “We give our team mem- bers responsible for these significant responsibilities adequate time to do their work. We also invest in education, such as webinars and in-person semi- nars, so they learn how to best perform their jobs. You cannot expect someone to walk into these positions and not require at least some support.”


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