By Debbi Conn, CRO, RN, LHCRM, Universal Healthcare Consulting, Inc.
Whether its state, federal or accrediting body surveys, when the surveyor walks in your door, the stress level rises and the nerves come to life. We like to think that we do things the "right" way all the time, but when under the scrutiny of a surveyor we all question ourselves. Surveyors can definitely be intimidating. The accrediting body surveyors are supposed to be there to evaluate and educate whereas the federal surveyors are there to identify areas of non-compliance. If the survey is scheduled there is time to prepare; however, the unannounced surveys are demanding of time and attention on days that may be very busy. Surveyors do not care- they are there for a purpose.
Many inspectors will follow a tracer patient to determine the level of compliance in all areas of the patient experience from check in until discharge from the facility. Infection control practices are an area of focus for the inspector while following the tracer patient. Hand washing and proper gloving technique are the first to be observed. Swabbing the medication vials prior to inserting the needle is an area where most deficiencies are found. The inspector will take note of pre-filled syringes and whether they are properly labeled. Additionally the dating of multi-dose vials should also be adhered to as per the facility's policies.
What Standards the facility's policies follow are at the discretion of the facility, and they could be a mix of standards from different authoritative bodies. Most facilities maintain the infection control standards of APIC for single use items, the CDC for multi-use medications, WHO for surgical safety and handwashing, AORN for sterilization, SNGA for endoscopy, and OSHA for Bloodborne Pathogens. Education to ensure that all staff and credentialed providers are aware of the standards will ensure that adherence is maintained and surveyors receive the correct answers to their questions.
Appointing a facility infectionist must be clearly documented and this person must be educated on the facility's infection control standards and how they apply to the facility. There are some great on-line courses as well as memberships to APIC and other organizations that offer infectionist education. Proof of training must be present in the infectionist's personnel file.
Infection control is not limited to the day of surgery, but includes monthly queries that are sent to all surgeons. Many surgeons do not perform follow up visits at the surgery center. Any infection that is identified within 30 days of surgery is required to be reported to the facility and investigated by the facility to ensure that all sterilization parameters passed and that any other patients that were in the facility on that day of surgery are free from infection. Occurrence reporting with tracking and trending should be performed to monitor personnel, the operating room, instrument sterilization and other common denominators that may be recurrent.
A well developed policy on infection control along with the appointment of a facility infectionist coupled with staff education will reduce the level of stress in one of the major areas of the inspection process.
For more information regarding this topic and other risk management and compliance issues
please feel free to contact Universal Healthcare Consulting at 888-457-0393.