1. Infection Prevention in ASCs: Innovative Tools for Program Improvement
Mary T. Post, RN, MS, CNS, CIC
Infection Prevention Specialist
Oregon Patient Safety Commission

2. Welcome
Thank you to the Oregon Health Authority’s Department of Healthcare Regulation and Quality Improvement (HCRQI) for sponsoring the training workshops
Debra Hurst, Infection Preventionist, will be co-presenting with Mary today
Copies of all of the slides are available on the flash drives you will receive this afternoon

3. Toolkit Resources
The toolkit will be available on the OPSC website and will be updated on an ongoing basis:
Copies of the tools are also available on the flash drives you received at registration
The packets you received during registration include an outline of today’s workshop schedule, paper for notes, a course evaluation, as well as samples of some of the tools that will be discussed

4. A Word About The Tools
The tools are designed to be downloaded and converted for use at your facilities
Replace the OPSC logo with your own logos
Review the tools and alter them as appropriate to fit your facility (i.e., some components might not be applicable to your setting)
Be certain you do all of the things you say you are doing
Areas highlighted in yellow require special attention, such as a need for you to fill in the blank or provide more facility specific information

5. Disclaimer
The Commission will attempt to periodically provide updated materials as warranted (e.g., standards change). However, it does not replace the need for someone at your ASC to stay abreast of changes.
All data and information provided by the Oregon Patient Safety Commission is for informational purposes only. The Oregon Patient Safety Commission makes no representations that the patient safety recommendations will protect you from litigation or regulatory action if the recommendations are followed. The Oregon Patient Safety Commission is not liable for any errors, omissions, losses, injuries, or damages arising from the use of these recommendations.

6. Workshop Objectives
At the end of the learning session, participants will be able to:
Design and implement an effective infection prevention program
Utilize a set of tools highlighting proven infection prevention processes
Reduce infection risks and better protect patients
Utilize tools to ensure ongoing infection prevention program regulatory compliance

7. Program Overview Infection Prevention Program Development
General Infection Prevention Practices
Cleaning, Sterilization and Disinfection
Environmental Hygiene
Employee Health Program
Safe Injection Practices and Safe Handling of Point of Care Devices
Toolkit Implementation: Influencing Behavior
Infection Prevention Program Development
Survey tools for success
Infection Prevention Program Assessment tools
GENERAL IC Practices
Hand & Respiratory Hygiene
Surgical Skin antisepsis
Standard Precautions
Isolation Practices
Reporting Infections
Needle safety
Cleaning, Sterilization & Disinfection
Use of sterilizers, competencies, high level disinfection, Loaner Instruments, Rounds tool
Environmental Hygiene
Cleaning policies/procedures
QC Checks
Employee Health Program
Screening & immunization requirements
Hep B & Influenza Declination forms
Skin test documentation forms
Employee Communicable disease policies
Blood/body fluid exposure policies
Safe Injection Practices/Disinfection of Point of Care Devices
Medication, drops, solution handling and storage
Point of Care Device Safe Handling and Disinfection Policy

8. Infection Prevention Program (Ipp) Development
Mary T. Post, RN, MS, CNS, CIC
Infection Prevention Specialist
Oregon Patient Safety Commission

9. Objectives
Describe common findings identified by Oregon Healthcare Regulatory and Quality Improvement (HCRQI) and Center for Medicare/Medicaid ASC surveys related to Infection Prevention Program (IPP) design
Discuss utilization of tools designed to assist with IPP development
Complete an IPP assessment and develop a written IPP plan

10. History Behind HCRQI ASC IPP Grant
National Centers for Medicare and Medicaid Services (CMS) Revised Standards and their Survey Findings
HCRQI ASC Survey Findings
Events reported to the Oregon Patient Safety Commission
Grant funding was available to support the
ASC Infection Prevention Program Development 

11. Table 3. Types of Lapses Identified in the Pilot Ambulatory Surgical Centers by Facility Type
Schaefer, M. K. et al. JAMA 2010;303:

12. Table 1: Frequency of ASC IPP Related Citations by Categories*
Tag Citation
Citation Frequency
Administration of Drugs 26
Infection Control Program 17
Performance Improvement Projects 12
Safety 11
Sanitary Environment 10
Quality Assessment & Performance Improvement 7
Infection Control Program-Responsibilities 5
Infection Control 4
Infection Control Program-Direction
Infection Control Program-QAPI 2
QA PI (7) & IC Program (4) were conditional level standards . ADD number of surveys.
*Surveys conducted from July 1, 2009 to April 11, 2011

13. CMS Questions for Infection Prevention Programs
Does the ASC have an explicit IPP?
Does the ASC’s IPP follow nationally recognized infection control guidelines? (document consideration and selection)
Does the ASC have a licensed healthcare professional, qualified through training in infection control, designated to direct the IPP? (Time spent per week should take into consideration size/scope/volume of ASC)

14. Oregon Requirements
IC program overseen by a multi-disciplinary committee responsible for investigating, controlling, and preventing infections in the facility
Annual review of policies for identification of existing or potential infection in patients, employees, medical staff, healthcare workers (HCWs) with ASC privileges
Control of factors affecting the transmission of infections and communicable diseases
Provisions for orienting & educating all employees, etc. on the cause, transmission, and prevention of infections
Collection, analysis, and use of data relating to infections in the ASC

15. Oregon Requirements (cont.)
Orientation and education of all employees, medical staff, healthcare professionals (HCPs) with ASC privileges and volunteers on the cause, transmission and prevention of infections
Collection, analysis, and use of data relating to infections in the ASC

16. Infection Prevention Needs to be Included in Your QAPI Program
Measure, analyze, track quality indicators
Written documentation of Quality Assurance and Performance Improvement (QAPI) activities recorded quarterly
Set priorities to focus on high risk, high volume, problem prone areas
Consider incidence, prevalence and severity of problems in those areas
Affect health outcomes, patient safety, and quality of care

17. HCRQI Infection Control Program Findings
Infection prevention (IP) surveillance programs not included in QAPI
Documentation of approved IP policy and procedure or annual review not evident
Orientation and annual IP education for all employees and volunteers not evident
IPP not under the designated direction of someone trained in infection control

18. Tip: Designated Individual Overseeing Infection Prevention Program
If you are designating a hospital IP or health department contact as the individual overseeing your IPP:
Have documentation of their involvement with your ASC
Policy and procedure review under hospital oversight
Have documentation of their involvement with your ASC (i.e., attendance meetings, site surveys)
Policy and Procedure review under hospital direction (have updated policies, signed, etc.) Survival tip.
BE CERTAIN THEY KNOW IT!

19. Quality Assurance and Performance Improvement
Program not reflective of scope and complexity of services provided
A description including data collection frequency, measures, and selection rationale were not documented
Performance improvement (PI) activities, findings, and corrective actions not documented or shared with employees and providers
Governing body oversight not demonstrated
Mixture of citation descriptions and samples of findings

20. The Most Important Thing to Take From Today
Infection Prevention Programs need to be dynamic, constantly evaluating itself, comparing itself to established goals, and reassessing itself
The planning process and annual assessment is CRITICAL!
DOCUMENT THE PROCESS YOU USED!

21. Annual IPP Planning
Plan
Set Goals
Implement
Evaluate

22. Annual IPP Risk Assessment
The organization identifies risks for acquiring and transmitting infections
Do your risk assessment: include ASC surveillance data findings, geographical risks, high risk populations, procedures, new services, etc.
Based on identified risks, set goals to minimize the possibility of transmitting infections
Reduce blood and body fluid exposure (BBFE) and communicable disease exposures, hand hygiene, eliminate the use of infections associated with the use of medical equipment, devices, and supplies, limit the transmission of infections associated with procedures

23. Tools to Support Risk Assessment
3 Survey Tools
ASC Environmental Rounds (1.01)
Operating/Procedure Room (1.02)
Sterile Processing and High Level Disinfecting (1.03)
IPP Risk Assessment Hazard Scoring Tool (1.04)
IPP Risk Assessment Surveillance Data Collection Tool (1.05)
IPP Annual Goals Evaluation Tool (1.06)

24. Rounds Survey Tools Detail oriented Educational tool QAPI tool
Assist with root cause analysis
Assist with ongoing regulatory compliance
Can be broken up and surveyed at different times
Use findings in your annual risk assessment
References from standards available soon

25. Operating/Procedure Room Observation Tool

26. Operating/Procedure Room Observation Tool
Designed to be used for operating/procedure room observation
Circle “yes” or “no” under compliant
If red box around answer, consider action plan
Traffic audit goal to decrease door openings, track reasons
CMS enforcing CDC Surgical Site Infection Prevention Guidelines
Attire AORN Fall 2010 revised guidelines (best practice)
Hand scrub (scrub brush vs. surgical rub)

27. ASC Environmental Rounds Survey Tool

28. ASC Environmental Rounds Survey Tool
Designed for use in non-OR areas
Assesses observed findings as well as staff knowledge
Circle “yes” or “no” under compliant
If red box around answer, consider action plan
Includes medication storage/handling

29. Sterile Processing & High Level Disinfection Rounds Tool

30. Sterile Processing & High Level Disinfection Rounds Tool
Designed to assess instrument handling from point of use through distribution of processed (sterilized or high level disinfected) instrument
Includes rounds in decontamination area
Identifies documentation requirements
Assesses compliance with storage requirements

31. IPP Risk Assessment Surveillance Data Collection Tool

32. How to Use the Surveillance Data Collection Tool
Modify to mirror data you collect (e.g., SSI rates)
Include things you should be monitoring (hand hygiene rates, employee exposures, flu vaccination rates)
Trend rates for three years (if possible) and average; compare to benchmark rate (if available)
Determine if you are doing better or worse and decide if you need to address it in your IC plan

33. IPP Risk Assessment
Hazard Scoring Tool

34. How to Use the Hazard Scoring Tool
Use findings from rounds, occurrence reports, surveillance data, and population risk assessments
Rate probability of occurrence (i.e., Frequent, Occasional, Uncommon, Remote)
Rate risk/impact severity to patient and to staff (Life Threatening, Permanent Harm, Temp Harm, None or non-applicable)
Rate level of preparedness (Poor, Fair, Good)

35. Risk Factor Severity of Effect and Regulatory Requirement Column
Total the score from all categories; add to column
Determine if there is a regulatory requirement (R) that requires you to address it in your plan (e.g., TB control, Influenza vaccinations)
Prioritize activities based on risk scoring and determine how you will mitigate the risk (i.e., what you plan to do about it)
Note: the score is used as a guide to help you prioritize

36. How to Use Hazard Scoring Tool Monitoring, Mitigation & Remediation Column
Decide if you will have a policy (P)
Determine if you will include it in your Performance Improvement Program (PI)
Determine if it requires ongoing data collection/monitoring (QA), but does not warrant a PI plan
Determine if it will go to the Infection Control Committee (ICC) for further discussion, action, or reporting

37. Infection Prevention Program Plan
The organization has an infection prevention program plan that includes:
Use of evidence based guidelines
Surveillance activities
Written description of how to evaluate the findings
Written description of the process for investigating outbreaks of infectious diseases
All components, functions, and activities are integrated
Method to communicate concerns, findings to LIPs, staff, visitors, patients, families
Report externally to other organizations

38. Your IPP Plan Should Address CMS Questions
Does the ASC have a system to actively identify infections that may be related to procedures performed at the ASC?
How does the ASC obtain this information?
How is supportive documentation confirming the tracking activity maintained?

39. Infection Prevention Program Plan

40. The Toolkit has an IPP Plan
You will need to spend time individualizing the plan so that it is reflective of your specific findings related to your risk assessment, barriers, etc.

41. ICC Should Participate in the Evaluation Process
ICC should review all risk assessment documents and approve of findings
ICC needs to be involved with annual program evaluation
ICC needs to approve of IPP annual goals and plan
Results of annual evaluation and planning should be shared with all staff

42. Implement Plan Use Standard Precautions
Personal Protective Equipment (PPE)
Transmission-based Precautions
Outbreak investigations (examples)
Infectious waste plan
Report and communicate findings and concerns
Report to external agencies as required/appropriate; show relationship of working with them
Notify receiving/transferring agencies

43. Evaluate Effectiveness of Plan
At least annually and when risks significantly change
Evaluate plan success, shortcoming, barriers
Prioritized risks
Plan goal
Activities
Involve the multi-disciplinary ICC in your annual evaluation and program planning; communicate findings from the evaluation to employees
Use findings to revise the plan!

44. Toolkit has IPP Annual Goals Evaluation Tool

45. IPP Annual Goals Evaluation Tool
List the goal
Identify the objective(s) of the goal
Document/summarize the actions taken to address the goal over the past year
Identify barriers to achieving the goal
Fold the findings into your assessment and planning for next year
Set new goals

46. Annual IPP Planning
Plan
Set Goals
Implement
Evaluate

48. Questions

49. Contact Information
Mary T. Post, RN, MS, CNS, CIC
Infection Prevention Specialist
Oregon Patient Safety Commission
1020 SW Taylor Street, Suite 700
Portland, OR