Build an Effective Infection Prevention Program Rely on sound policies, careful training and accountability BY ALISON SONSTELIE

ASC employees often wear multiple hats and fill multi- ple roles that are normally individualized at larger facilities. In some cases,

surgery centers have tight reprocess- ing areas or limited equipment, tools or chemistries to reprocess devices. Hav- ing access to the most updated instruc- tions for use (IFU) is critical for success in this field and these situations. Despite the challenges, several dynamics can work in an ASC’s favor. Smaller physical space and fewer employees, for example, can create opportunities to intensify quality con- trol processes and tighten corners to improve infection prevention practices. To develop an effective infection prevention and compliance program, an ASC must build elements of stan- dard operating procedures, education, competency, accountability and qual- ity control into its processes. The base of compliance is the cre-

ation and development of standard operating procedures and policies. Luckily, we have evidence-based stan- dards and guidelines, manufacturer’s IFU and regulations available to ensure we are setting ourselves up to follow best practices.

dures and policies

Once standard operating are

proce- established,

the next step is developing training and education programs to ensure the team can apply them to situations they encounter during their daily work. After training is complete, the ASC needs to verify that the employee is competent at performing the tasks required. Competency can be demon- strated in a variety of ways, such as a question-and-answer quiz or by hav- ing the employee perform the required

22 ASC FOCUS MAY 2021 | Compliance

Quality Control Accountability

Competency Verification Training and Education

Standard Operating Procedures and Policies SOURCE: ALISON SONSTELIE

tasks. Having a system that is used to document employees’ training and competency is important, as it ensures education is performed appropriately. Surveyors may ask to see these records during an inspection. Once competency is verified, it is

critical to develop methods to keep employees accountable for the work they perform. Choosing to take short- cuts or skip steps in a task is a risk to patient safety and must be addressed with employees as soon as possible. Often, when steps are skipped, it is because the employee does not under- stand why the step is critical to the outcome of the task. This is an oppor- tunity to teach and explain, not neces- sarily reprimand.

The next step in developing an

effective infection prevention program is implementing a quality control sys- tem that can be used to verify that the steps in the process are delivering the expected results. This can be done with

audits, by tracking issues and non- compliance to processes, and by col- lecting feedback from the team. If your results are not what you expect, the time has come to do a root cause analysis to see where the process is breaking down. Once these elements are put into place, you have a solid foundation to achieve compliance. The steps do not have to be perfect, but your ASC should have an expectation of contin- uous improvement in the details that will lead to improved compliance. Let us examine a real-world exam-

ple. Your surgery center purchases a new model of flexible endoscopes to use in a new procedure your facility plans to perform. Consider taking the following steps to ensure compliance to the manufacturer’s IFU, evidence- based guidelines, and state and federal regulations: 1. For reprocessing, review the manufacturer’s instructions

for use (before purchase, if possible) The advice and opinions expressed in this column are those of the author and do not represent official Ambulatory Surgery Center Association policy or opinion.

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