Meeting CMS Requirements for Infection Prevention in Ambulatory Surgery Centers

1
Meeting CMS Requirements for Infection Prevention
in Ambulatory Surgery Centers

• September 18, 2012
• APIC Badger Chapter
• Madison, WI
• Presenter
• Judy Hintzman RN MS CIC

2
Objectives

• Understand the elements of infection prevention
  and control in ambulatory settings surveyed by
  CMS.
• Describe how to perform a facility risk
  assessment.
• Identify the initial steps in implementing change
  in your organization.

3
Centers for Medicare and Medicaid Services (CMS)

• Federal agency that administers
• Medicare and Medicaid
• HIPAA
• Enforces federal quality standards for various
  healthcare settings
• Maintains oversight of ASCs, long term care
  facilities, home health agencies, intermediate
  care facilities, mental health facilities and
  hospitals
• Administers Quality Improvement Organizations at
  state level

4
What Led to the Focus on Infection Control in
ASCs?

• Cluster of Hepatitis C virus infections (Nevada)
  related to endoscopy procedures
• Survey of that ASC identified unsafe injection
  practices resulting in 40,000 patients notified
  of potential exposure.
• Nevada also identified other ASCs with deficient
  infection control practices.
• CDC has reported other outbreaks related to
  bloodborne infectious diseases in other states.

5
CMS Conditions for CoverageInfection Control
Requirements 5/18/09

• 416.51 Infection Control The ASC must maintain an
  infection control program that seeks to minimize
  infections and communicable diseases.
• Standard A Sanitary Environment The ASC must
  provide a functional and sanitary environment for
  the provision of surgical services by adhering to
  professionally acceptable standards of practice.

6
CMS Conditions for CoverageInfection Control
Requirements 5/18/09

• Standard B Infection control program. The ASC
  must maintain an ongoing program designed to
  prevent, control, and investigate infections and
  communicable diseases. In addition, the
  infection control and prevention program must
  include documentation that the ASC has
  considered, selected, and implemented nationally
  recognized infection control guidelines.

7
CMS Conditions for CoverageInfection Control
Requirements 5/18/09

• The program is
• (1) Under the direction of a designated and
  qualified professional who has training in
  infection control
• (2) An integral part of the ASCs quality
  assessment and performance improvement program

8
CMS Conditions for CoverageInfection Control
Requirements 5/18/09

• The program Is
• (3) Responsible for providing a plan of
  action for preventing, identifying, and managing
  infections and communicable diseases and for
  immediately implementing corrective and
  preventive measures that result in improvement.

9
What is an Ambulatory Surgical Center or ASC (per
CMS)?

• Any entity that operates exclusively for the
  purpose of providing surgical services to
  patients not requiring hospitalization
• Duration of services not expected to exceed 24
  hours

10
What is Surgery per CMS?

• Procedure performed for purpose of structurally
  altering the human body by incision or
  destruction of tissues.
• Diagnostic or therapeutic treatment of conditions
  or disease processes by any instruments causing
  localized alteration or transposition of live
  human tissue which includes lasers, ultrasound,
  ionizing radiation, scalpels, probes and needles.
  Endoscopy is included in definition.
• Injections of substances into body cavities,
  internal organs, joints, sensory organs, and the
  central nervous system.

11
The ASC Survey Process for CMS

• Certification accomplished through
• Observations and tours
• Interviews
• Document and record reviews

12
Survey ProcessNo more drive by CMS surveys
October 2009 - first training in 10 years

• Focus on staff that do procedures
• Case tracer methodology
• Surveyors required to follow at least one patient
  from admission, through surgery and recovery, to
  discharge.
• Infection control surveyor worksheet is used to
  collect information (16 pages)

13
Accreditation StandardsMust be met to receive
accreditation

• Government regulations- CMS - OSHA
• ASC accrediting agencies
• AAAHC Accreditation Association for Ambulatory
  Health Care
• AAAASF American Association for Accreditation for
  Ambulatory Surgery Facilities
• AOA American Osteopathic Association
• Best practices may become standard of care
• Guidance documents
• CDC, DHQPA,NHSN,NIOSH,HICPAC, AAMI, APIC
• Environmental Infection control
• Terminal cleaning of OR room
• Prevention of Surgical Site Infection
• Have you read CDC document?
• How is information shared when SSIs are
  identified?
• Hand Hygiene
• Have you read the CDC document?
• Have you done observation studies on compliance?

14
Infection Prevention Program Required Elements

• Written plan
• Risk assessment
• Qualified licensed professional to direct the
  program
• Education in Infection Prevention is documented
• Can be certified but not required
• Selection of nationally recognized guidelines
• Available to staff and current
• Evidence of compliance with guidelines
• Surveillance system including notifiable disease
  reporting to State
• Staff education and training
• Must have an annual plan
• Documented training

15
CMS ASCInfection Control Worksheet (ICWS)

• Initial tool developed by CDC as part of Nevada
  Outbreak investigation
• 10 million funding made it possible to increase
  ASCs surveys and implement process nation wide
• Some accreditation organizations are also using
  the ICWS
• Original goal collect ICWS from 1500 ASCs

16
CMS Survey Outcomes

• No Deficiency
• Standard Level
• Condition Level
• Immediate Jeopardy

17
Focus on Specific Infection Prevention Practices

• Hand Hygiene (including glove use)
• Safe injection practices (including use of
  medication vials)
• Disinfection and sterilization
• Environmental infection control
• Safe use and handling of point of care devices

18
ASCs Characteristics Sample Questions

• 1) ASC name
• 2) Address
• 3) 10-digit CMS Certification Number
• 4) What year did the ASC open for operation?

19
ASCs Characteristics Sample Questions

• What is the primary procedure performed at the
  ASC (i.e., what procedure type reflects the
  majority of procedures performed at the ASC).
  Check only ONE
• ? Dental ? Orthopedic
• ? Endoscopy ? Pain
• ? Ear/Nose/Throat ? Plastic/reconstructive
• ? OB/GYN ? Podiatry
• ? Ophthalmologic ? Other

20
ASCs Characteristics Sample Questions

• What additional procedures are performed at the
  ASC (Check all that apply)?
• ? Dental ? Orthopedic
• ? Endoscopy ? Pain
• ? Ear/Nose/Throat ? Plastic/reconstructi
  ve
• ? OB/GYN ? Podiatry
• ? Ophthalmologic ? Other ____________

21
ASCs Characteristics Sample Questions

• Who does the ASC perform procedures on? (Check
  only ONE)
• ? Pediatric patients only
• ? Adult patients only
• ? Both pediatric and adult patients

22
ASCs Characteristics Sample Questions

• What is the average number of procedures
  performed at the ASC per month?
• How many Operating Rooms (including procedure
  rooms) does the ASC have?
• of rooms
• actively maintained

23
ASCs Characteristics Sample Questions

• Please indicate how the following services are
  provided (check all that apply)
• Anesthesia ?Contract ? Employee ? Other____
• Environmental Cleaning ?Contract ? Employee ?
  Other ____
• Linen ?Contract ? Employee ? Other ____
• Nursing ?Contract ? Employee ? Other ____
• Pharmacy ?Contract ? Employee ? Other ____
• Sterilization/Reprocessing ?Contract ? Employee
  ? Other ____
• Waste Management ?Contract ? Employee ? Other
  ____

24
Worksheet Standard Assessment

• Does the ASC have an explicit infection control
  program? ? YES ? NO
• NOTE! If the ASC does not have an explicit
  infection control program, a condition-level
  deficiency related to 42 CFR 416.51 must be
  cited.

25
Worksheet Standard Assessment

• Does the ASCs infection control program follow
  nationally recognized infection control
  guidelines?
• ? YES ? NO
• NOTE! If the ASC does not follow nationally
  recognized infection control guidelines, a
  deficiency related to 42 CFR 416.51(b) must be
  cited. Depending on the scope of the lack of
  compliance with national guidelines, a
  condition-level citation may also be appropriate.

26
Worksheet Standard Assessment

• Is there documentation that the ASC considered
  and selected nationally-recognized infection
  control guidelines for its program?
• ? YES ? NO

27
Worksheet Standard Assessment

• Which nationally-recognized infection control
  guidelines has the ASC selected for its program
  (Check all that apply)?
• NOTE! If the ASC cannot document that it
  considered and selected specific guidelines for
  use in its infection control program, a
  deficiency related to 42 CFR 416.51(b) must be
  cited. This is the case even if the ASCs
  infection control practices comply with generally
  accepted standards of practice/national
  guidelines. If the ASC neither selected any
  nationally recognized guidelines nor complies
  with generally accepted infection control
  standards of practice, then the ASC should be
  cited for a condition-level deficiency related to
  42 CFR 416.51

28
Worksheet Standard Assessment

• Does the ASC have a licensed health care
  professional qualified through training in
  infection control and designated to direct the
  ASCs infection control program?
• ? YES ? NO
• is this person an (check only ONE)
• ? ASC employee
• ? ASC contractor

29
Worksheet Standard Assessment

• Is this person certified in infection control
  (i.e., CIC)
• (Note 416.50(b)(1) does not require that the
  individual be certified in infection control.)
• ? YES ? NO
• If this person is NOT certified in infection
  control, what type of infection control training
  has this person received?

30
Worksheet Standard Assessment

• On average how many hours per week does this
  person spend in the ASC directing the infection
  control program?
• Note 416.51(b)(1) does not specify the amount
  of time the person must spend in the ASC
  directing the infection control program, but it
  is expected that the designated individual spends
  sufficient time directing the program, taking
  into consideration the size of the ASC and the
  volume of its surgical activity.)

31
How Many IC Hours per Week?

• Does not specify
• The amount of time needed to direct the program
  is relative to the size and scope of service
• Judys thoughts - at least 3 times a week- 4
  hours per day until the program is established.
  There is lots to do!

32
Worksheet Standard Assessment

• Does the ASC have a system to actively identify
  infections that may have been related to
  procedures performed at the ASC? ? YES ? NO
• If YES, how does the ASC obtain this
  information?
• Sends e-mails to patients' after discharge.
• Follows up with patients primary provider after
  discharge.
• Relies on the surgeon at a follow up visit to
  report
• Other

33
Worksheet Standard Assessment

• Is there supporting documentation confirming this
  tracking activity?
• ? YES ? NO

34
Worksheet Standard Assessment

• Does the ASC have a policy/procedure in place to
  comply with State notifiable disease reporting
  requirements?
• ? YES ? NO

35
Worksheet Standard Assessment

• Do staff members receive infection control
  training?
• ? YES ? NO
• If YES,
• How do they receive infection control training
  (check all that apply)?
• ? In-service
• ? Computer-based training
• ? Other (specify)

36
Worksheet Standard Assessment

• Which staff members receive infection control
  training? (check all that apply)
• ? Medical staff
• ? Nursing staff
• ? Other staff providing direct patient care
• Staff responsible for on-site sterilization/high-
• level disinfection
• ? Cleaning staff
• ? Other (specify)

37
Worksheet Standard Assessment

• Is training
• The same for all categories of staff ?
• Different for different categories of staff ?

38
Worksheet Standard Assessment

• Indicate frequency of staff infection control
  training (check all that apply)
• ? Upon hire
• ? Annually
• ? Periodically/as needed
• Other (specify)

39
Survey Process

• Tracer methodology
• Focus on staff who perform procedures
• Injection practices nurses physicians
• Instrument reprocessing reprocessing
  technicians

40
Hand Hygiene

• Challenging to assess
• Observations in patient-care areas
• Pre-operative area
• Post-operative area
• Focus on
• Nurses
• Physicians

41
Hand Hygiene

• Soap and water available
• Alcohol-based hand rubs available and installed
  as required
• Staff perform hand hygiene correctly
• After removing gloves
• After direct patient contact
• Before performing invasive procedure

42
Glove Use

• Healthcare providers should wear (non-sterile)
  gloves
• For procedures that might involve contact with
  blood or body fluids
• When handling potentially contaminated patient
  equipment
• Healthcare providers should remove gloves (and
  immediately perform hand hygiene) before moving
  to the next task and/or patient

43
Gloves Common Mistakes Seen

• Failure to clean hands after gloves removed.
• Moving from patient to patient without cleaning
  hands and changing gloves
• Using alcohol based hand rub on gloves
• Thinking double gloving protects against puncture
  injury
• Not having gloves accessible in locations where
  they are needed/ and used.

44
Injection SafetyInjectable medications, saline,
other infusates

• Observations in patient care and medication
  preparation areas
• Pre-operative area
• Operating/Procedure rooms
• Anesthesia cart
• Focus on
• Nurses (e.g., RN, CRNA)
• Physicians (e.g., anesthesiologists)

45
Injection Practices
46
Injection Safety

• Needles are used for only one patient
• Syringes are used for only one patient
• Medication vials are always entered with
• New needle
• New syringe

47
Handling of Single-dose Medications and Supplies

• Single-dose medication vials
• Manufacturer-prefilled syringes
• Bags of IV solution
• Medication administration tubing and connectors

48
Handling of Multi-dose Medications

• Rubber diaphragm is disinfected with alcohol
• prior to each entry.
• Vials are dated when opened and discarded within
  28 days or according to manufacturer
  instructions, whichever comes first
• Vials are not stored or accessed in the immediate
  areas where direct patient contact occurs (e.g.,
  at patient bedside)

49
Label Requirements are Strictly Enforced

• Medications that are pre drawn are labeled with
  the time of draw, initials of the person drawing,
  medication name, strength and expiration date or
  time.
• There are NO acceptable work arounds or
  substitute practices to avoid using a label.

50
Inspection Of Multi-Dose VialsNeed a policy and
assure practice

• Multi-dose vials used on gt1 patient
• Vial septum disinfected with alcohol before entry
• New needle and syringe for each access
• Vials are dated when opened and discarded in 28
  days or manufacturers expiration date, which
  ever comes first.
• Reminder single dose and multi-dose vials are
  not interchangeable.
• Drug cost/availability does not justify doing so.

51
Surveyors will look in more than one place for
injection safety deficiencies

• Important Reminders
• Per CDC, medications should be drawn up as close
  to the point of use as possible
• Do not carry over pre drawn syringes from one
  day to the next, discard at the end of the day.
• Do not spike your IV bags and sets before they
  will be used
• NEVER use a bag of saline to pre fill syringes
• NEVER combine the leftover contents in
  partially used vials.

52
A frequently asked question.Do CMS and CDC
permit incremental dosing? YES but only when

• Same syringe, same drug
• Required intra-operatively
• No opportunity to reuse with another patient
• Anesthesia most common scenario

53
Sterilization
54
Sterilization

• Pre cleaned
• Visually inspected
• Chemical indicator is used
• Biologic indicator is performed at least weekly
• Documentation for each sterilizer is maintained
  and up to date and includes results from each load

55
Flash Sterilization Update

• Past Definition very short cycle for small and
  unwrapped load.
• Sterilization of unwrapped/uncontained loads
  should be used for urgent and unpredicted need
  (e.g. dropped instrument).
• Routine sterilization of unwrapped/uncontained
  loads is inappropriate and will be cited as a
  violation by CMS.

56
Short Sterilization Cycle (Flash Sterilization)

• Short sterilization cycle of wrapped/contained
  load is OK
• Requirements
• Sterilizers cleared by FDA to run short cycles
• Validated by manufacturers to perform
  effectively in those cycles for defined
  validation loads.

57
Short Sterilization CycleSurveyor will ask these
questions.

• Is sterilizer labeled for this cycle by
  manufacturer?
• What is the manufacturer-recommended load for
  that cycle?
• Is the containment device used labeled by
  manufacturer for use in that cycle?
• For what load is the containment device
  recommended by its manufacturer?
• Is the chemical indicator (and biological if
  used) labeled for use for this cycle by the
  manufacturer?
• If the cycle is used frequently, is it checked
  regularly with a biological indicator?

58
Short Sterilization Cycle

• Factors to consider that will influence outcome
• Weight and complexity of materials in the load
• Presence or absence of fabric in load
• Presence or absence of lumens

59
Short Sterilization Cycle

• If manufacturers instructions are not followed ,
  then the outcome of the sterilizer cycle is
  guesswork, and the ASCs practices will be cited
  as a violation.
• Surveyors will also observe whether adequate pre
  cleaning is being performed with water and
  detergent or water and enzymatic cleaners.

60
High Level Disinfection

• Semi critical equipment is high level disinfected
  or sterilized
• Items are pre cleaned and visually inspected
• Equipment is maintained
• Chemicals are prepared, tested and replaced
  according to manufacturers recommendations.
• Items are allowed to dry before use
• Items are stored in designated clean area

61
JCAHOGuidance on Laryngoscope Blades

• Per CDC Laryngoscope blades are semi critical
  items. They should be sterilized or high level
  disinfected before reuse.
• Stored in a way to prevent recontamination.
• Examples of non compliant storage
• Unwrapped blades in an anesthesia drawer or top
  of a code cart
• Examples of compliant storage
• Peel pack (long term)
• Wrapping in sterile towel (short term)

62
JCAHOGuidance on Laryngoscope Blades

• Laryngoscope handles must be processed prior to
  use on next patient.
• Follow manufacturers recommendations
• Low level disinfectant on surface of handle
• Check with state for additional law or
  regulation.

63
Environmental Infection Control
64
Point of Care Devices

• Observation in
• Pre-operative area
• Post-operative area
• Focus on
• Nurses

65
Glucose TestingFinger stick Devices

• A new single-use, auto-disabling lancing device
  is used for each patient

66
Glucose TestingFingerstick Devices

• Lancing penlet devices should NOT be used for
  multiple patients

67
Point of Care Devices
68
Glucometers

• Glucometer is not used on more than one patient
  unless manufacturers instructions indicate this
  is permissible
• Glucometer is cleaned and disinfected after every
  use

69
CMS Visits To Date in Wisconsin

• 9/1/11- 8/31/12
• 30 surveys
• 1/1/12-8/31/12
• 19 surveys

70
Problem Prone AreasSanitary Environment- must
provide a sanitary environment by following
professionally acceptable standards of practice.

• Floors not clean
• Food prepared next to hand washing sinks and
  sharps containers
• Refrigerator/freezer temps not monitored
• Walls chipped
• Wet OR floors with blood/body fluids tracked
  outside OR suites

71
Problem Prone AreasInfection Control Program

• ASC has not decided on what nationally recognized
  standards will be followed.
• Hand washing/gloving by all staff
• Eye shields not worn in surgery
• Leaving the OR, going outside, reentering the OR
  without changing scrubs.
• Using glucose meters not for multiple patient use
• Enzymatic cleaner and water concentrations not
  measured per manufactures directions.

72
Problem Prone AreasInfection Control Program

• Sterile field broken-back to instrument table
• Staff not screened for infections and
  communicable diseases (TB, Rubella, Hepatitis)
• Recapping of needles two handed
• Oxygen tubing ready to use open to air
• CSS door propped open to hallways
• Boxes of patient supplies stored on floors

73
Problem Prone AreasInfection Control Program

• Flash sterilization used daily/frequently due to
  lack of appropriate number of instrument trays
• Lack of infection control program and active
  surveillance
• Using hand sanitizers on gloved hands
• Cross contamination between clean and dirty

74
Problem Prone AreasProgram under direction of a
qualified professional

• No one assigned by governing body who will lead
  the ASC IC program
• Not qualified
• Not enough time dedicated to do the job
• No training or on going education

75
Problem Prone AreasIC Director is responsible
for plan of action for preventing, identifying,
and managing infections and for implementing
corrective/preventive measures that result in
improvement

• ASC does not have active surveillance to ensure a
  sanitary environment and staff adherence to IC
  policies and current standards of practice
• Anesthesia/medical staff not included as part of
  active surveillance
• Not assessing the risks of type of procedures
  performed and type of staff who work in ASC
• Collection of data without analysis and action
  plans related to post op infections
• Does not have PP related to disease reporting to
  health departments.

76
Problem Prone Area The IC program is an integral
part of the ASCs quality assessment and
performance improvement program

• The ASC does not include measure/indicators and
  activities to IC into the QAPI program which
  governs all their patients
• No evidence that IC activities result in actions
  designed to improve IC within the ASC
• Judys passion is to show that all of our hard
  work actually improved patient care!

77
Elements of the Infection Surveillance,
Prevention Control Program

• Written Infection Prevention Control Plan
• Risk Assessment
• Authority statement
• IC Service Description
• Surveillance Plan
• Goals Objectives
• Prevention Control Strategies
• Communications Reporting
• Emergency Management Planning
• Education
• Evaluation of Program Effectiveness

78
Facility Risk AssessmentShould be done annually

• Provides a basis for IP activities/annual
  surveillance plan
• What populations do you serve?
• What communicable diseases are in the community?
• TB risk assessment must be done annually.
• Identify high risk populations in your facility
• High volume, high risk, or problem prone
  procedures
• Assist in focusing surveillance efforts
• Meet regulatory requirements
• Example OSHA requires biohazard waste to be
  contained and labeled correctly.

79
Facility Risk Assessment

• Introduction
• Identify who developed the document with
  collaboration from other team members (list)
• Geographic location/ community environment/
  demographics
• List counties, community issues and patients
  served
• Care, treatment and services provided
• Describe physical plant (ORs, Endo, procedures
  done)

80
Facility Risk Assessment cont.

• List characteristics that increase risk
• High volume cases, high risk procedures, implants
• Community outbreaks
• Resistant bacteria
• Identify any area that needs to be improved.
• List characteristics that decrease risk
• Education of staff to prevent infection
• Identify improvements/implementations
• Increased hand hygiene compliance
• Use of PPE especially gloves
• Follow CDC guidelines to prevent SSI
• Timing of antibiotics
• No razors

81
Resources Facility Risk Assessment

• Beckers ASC Review _at_ www.beckersasc.com
• Using an Infection Control Risk Assessment to
  Create an Infection Control Plan _at_
  www.icprofessor.com
• Association of Wisconsin Surgery Centers, Inc.
  (WISCA) Course scheduled December 2012 _at_
  www.wisc-asc.org

82
Facility TB Risk Assessment

• Risk assessment form specific for ambulatory
  care
• APIC Infection Prevention Manual for Ambulatory
  Care 2009 Section 9.
• Follow State Law
• Screen everyone on hire
• Medium risk annual screening
• Low risk no additional screening unless exposure
  occurs

83
Authority Statement Must be Written

• The Board of Directors (Medical Director/Quality
  Committee) authorizes and supports the Director
  (Manager/etc.) of Infection Prevention to
  institute appropriate infection control measures
  within the facility. This includes authority to
  employ whatever methods necessary when, in their
  judgment, there is reasonable possibility of
  immediate danger to any patient's), personnel or
  others in the facility.

84
Surveillance PlanShould be done annually

• How surveillance methodology
• How will data be collected?
• What indicators and events will be counted?
• Outcome monitors
• Surgical site Infections
• Process monitors
• Hand Hygiene rate
• Influenza immunization rates
• Terminal cleaning done correctly
• Why reduce risk improve patient care
• Comparative databases should be used
• Outbreak identification and response should be
  planned

85
Healthcare Associated Surgical Site Infections
(SSI)

• Definition of SSI should be written and utilized-
  provide definitions to surgeons.
• Surveillance system must be in place to identify
  and evaluate every infection
• Develop a process for case finding (patient
  education should include signs and symptoms to
  look for and emphasize infection prevention
  strategies)
• Record variables for every procedure being
  monitored (surgical wound class, ASA
  classification, duration of operation)
• Report SSI info to the surgical team on a routine
  basis (quarterly) and as each case occurs.

86
Healthcare Associated Surgical Site Infections
(SSI)

• Data collection should include
• Basic demographics (name, MR number, age, gender,
  date of procedure)
• Infection information (date of onset, site of
  infection, microorganisms)
• Clinical information ( signs and symptoms
  present)
• Laboratory information (date of culture, result)
• Antibiotic therapy (preop, therapeutic)
• Surgery information (date, start and stop times,
  surgeon, wound classification, and severity of
  illness ASA score )
• Procedure information (type, date)
• Predisposing factors( (diabetes, steroids, skin
  issues)

87
Use Nationally Recognized Guidelines to Reduce
Risk of Surgery-Related Infections

• Antibiotics administered right time, right
  antibiotic and discontinued appropriately after
  surgery.
• Aseptic technique
• Blood sugar control
• Pre op showers
• No shaving whenever possible
• No razors!

88
Implementing Change in your Organization

• First Steps
• Conduct your risk assessment
• Prioritize the needs of your organization

89
Implementing Change in your Organization

• Do not try to fix everything all at once.
• Make a list of available resources you already
  have.
• Identify what you do already?
• Identify a champion who can help.
• Identify small group of influential leaders
  committed to patient safety who can help
• Develop a plan of action (1-2 years)

90
Advice from Judy

• Meet with leadership-get support ASAP
• Identify the amount of time needed to accomplish
  all that must be done- stick to it!
• Create a plan of action ( 3 month , 6 month, 12
  month)
• Join APIC chapter
• Obtain necessary references to do the job
• Infection Control in Ambulatory Care 2004
• Infection Prevention Manual for Ambulatory care
  2009
• Develop a Facility Risk Assessment ASAP
• Develop a Surveillance Plan ASAP

91
What Are Some Barriers To Change?

• Unexpected changes in external conditions
• A lack of commitment in implementation
• Resistance of people involved
• Lack of resources
• Conflicting goals or priorities

92
How Can You Make Change Happen?

• Before implementing change, you need to convince
  people that change is needed
• Never, never underestimate the power of
  complacency

93
Skills Needed to Lead Change

• Commitment to the plan
• Realistic goal setting
• Communication skills
• Flexibility
• Ability to stimulate motivation in others
• Follow through

94
Summary

• The CMS regulations are a golden opportunity to
  improve patient safety in the ambulatory surgery
  setting, as well as employee safety.
• The emphasis on medication and injection safety
  and processing instruments and scopes is
  appropriate.
• This work will make a difference!

95
Questions?

• Thank You!
• Judy Hintzman RN MS CIC Infection Preventionist
• jhintzman1_at_yahoo.com
• 262-408-8130