3/2/18

Infection Prevention and Control Standards Challenge AAAHC-Accredited Organizations


By on 6:47 AM

Infection prevention- and control-related standards are among those with high deficiency percentages for organizations accredited by the Accreditation Association for Ambulatory Health Care (AAAHC).

This is according to AAAHC's Quality Roadmap 2017, the accreditor's annual review and analysis of standards compliance. The 2017 report reflects data from nearly 1,400 surveys conducted against AAAHC's 2016 standards. Surveyed organizations include ASCs, Medicare-deemed status ASCs, office-based surgery facilities and primary care settings.

Non-Medicare-Deemed Status ASCs

For non-Medicare-deemed status ASCs, standards rated as deficient at least 10% of the time, as a percent of all ratings for the standard, were identified. The following infection prevention- and control-related standards met this parameter (with % deficient included in parentheses):
  • 7.I.D.2 (14%) — The written infection prevention and control program is: The result of a formal, documented infection prevention risk assessment to ensure that the program is relevant to the organization.
  • 11.I (12%) — The organization must have policies in place for safe use of injectables and single use syringes and needles that, at minimum, include Centers for Disease Control and Prevention (CDC) or comparable guidelines for safe injection practices.

Medicare-Deemed Status ASCs

For Medicare-deemed status ASCs, standards rated as deficient on at least 19% of the surveys were identified. The following infection prevention- and control-related standard met this parameter (with % deficient included in parentheses):
  • 7.I.C.2 (19%) — The infection control and prevention program reduces the risk of health care-acquired infection as evidenced by education and active surveillance, consistent with: CDC or other nationally-recognized guidelines for safe injection practices.

Office-Based Surgery

For office-based surgical facilities, standards rated as deficient at least 10% of the time were identified. The following infection prevention- and control-related standards met this parameter (with % deficient included in parentheses):
  • 7.I.B.4 (12%) — The written infection prevention and control program is: The result of a formal, documented infection prevention risk assessment to ensure that the program is relevant to the organization.
  • 7.I.D.2 (14%) — The infection prevention and control program reduces the risk of health care-acquired infection as evidenced by education and active surveillance, consistent with: CDC or other nationally-recognized guidelines for safe injection practices.
  • 7.I.F.2 (12%) — Processes for the cleaning, disinfection, and sterilization of instruments, equipment, supplies, and implants adhere to: manufacturer’s instructions for use
  • 11.I (14%) — The organization must have policies in place for safe use of injectables and single use syringes and needles that, at minimum, include CDC or comparable guidelines for safe injection practices.

Primary Care Settings

For primary care organizations, standards rated as deficient at least 15% of the time were identified. The following infection prevention- and control-related standards met this parameter (with % deficient included in parentheses):
  • 7.I.B.4 (21%) — The written infection prevention and control program is: The result of a formal, documented infection prevention risk assessment to ensure that the program is relevant to the organization.
  • 7.I.C (16%) — The infection prevention and control program is under the direction of a designated and qualified health care professional who has training and current competence in infection control.
Note: The 2017 report is available for free download after filling out a form here.

Infection Control Consulting Services (ICCS), a national infection control and prevention consulting firm, reports that its findings during onsite visits and review of written programs in the outpatient setting, including ambulatory surgery centers and outpatient clinics, are consistent with this report.

ICCS assists outpatient facilities with developing written programs, risk assessments, goals and objectives, assessing the educational needs of qualified healthcare professionals, remediating suboptimal clinical practices and more. Contact Infection Control Consulting Services.

 

Phenelle Segal, RN, CIC, FAPIC

Phenelle Segal, RN, CIC, FAPIC, is the founder and president of Infection Control Consulting Services LLC (ICCS). Phenelle has more than 30 years' experience providing customized comprehensive infection control and prevention services to healthcare facilities nationwide. Her services focus on assisting hospitals, ambulatory surgery centers, dental office and oral surgery practices, doctor's offices, nursing homes and other organizations with implementing and maintaining an infection control program that: complies with The Joint Commission, AAAHC, Centers for Medicaid and Medicare Services (CMS) and other regulatory agencies; respond to situations of noncompliance; and improve the processes for reducing risk.

0 comments:

Post a Comment