When preparing for an accreditation survey, it is important to understand that the standards follow the pattern of addressing policy, implementation, evaluation, and reporting. Approaching the requirements as a to-do list is typically not a successful strategy to demonstrate compliance.
This was evident in the 2019 HFAP Quality Review, which found incomplete assessments, processes, and documentation were the top concerns cited during accreditation surveys in 2018. Your quality improvement team is critical in evaluating all clinical and clinical support processes and procedures from start to finish – making sure no key component is missing – as well as the results you are achieving.
This is especially vital when striving to meet infection prevention and control (IPC) standards, which are central to patient safety and quality of care. The 2019 HFAP Quality Review highlighted some of the most common accreditation survey citations regarding IPC from 2018, as well as HFAP surveyor insight on how best to improve performance and avoid deficiencies.
Ambulatory surgery centers
The most commonly cited IPC deficiency in the ambulatory surgery center (ASC) setting centered on environmental cleaning and decontamination across the organization with a focus on clinical and clinical support areas. A sanitary environment is directly related to infection control. The purpose of these standards is to prevent sources of transmission of infections and communicable diseases in all areas of the facility, understanding that nationally-recognized IPC guidelines are the basis for policies and procedures. Examples included:
· Insufficient cleaning or maintenance of light fixtures, vents, cabinets, ceilings, floors, walls, etc.
· Not following manufacturer’s instructions for cleaning and decontamination products
· Initiating the decontamination process while the patient is in the room
To help improve compliance, develop policies and procedures regarding cleaning, decontamination and sterilization that follow manufacturer’s guidelines and national IPC guidelines. Ensure staff have been properly trained in these policies and evaluate implementation through observable compliance. Does your staff “walk the talk”? The best policies are just words unless they are fully implemented.
In addition, regular environmental surveillance rounds to ensure cleanliness of all areas of the ASC keeps the importance of IPC top of mind for the entire team and avoids it being siloed to facilities and quality improvement teams. Share the results of your observations throughout your organization to further engage teams in prioritizing IPC efforts.
Acute care hospitals
In the acute care hospital setting, IPC protocol must span all departments, relying on collaboration between locations, departments and services to ensure consistency, and be integrated into the hospital-wide quality assessment and performance improvement (QAPI) program.
A sanitary environment is the cornerstone of IPC and it calls for broad, proactive and ongoing practices that address everything from immunizations and screening for infection, to training to prevent healthcare associated infections (HAI) and active surveillance. While the citations in acute care hospitals touched on everything from outdated policies to insufficient cleaning and storage policies, many of the solutions are minor adjustments “hiding in plain sight.” Examples include:
· An accumulation of systemic deficiencies found throughout a facility, from patient care areas and diet kitchen, to operating rooms and surgical service areas, resulted in Condition of Participation noncompliance
· Insufficient cleaning or maintenance of equipment, appliances, surfaces, vents and light fixtures
· Presence of significant rust throughout facility and on patient care instruments
· Outdated IPC policies and procedures with lack of efficient review protocol
Make it a priority to review IPC policies at least every three years by the IPC committee, but an annual review is preferred. Hospital teams should conduct regular IPC surveillance rounds and report findings to the QAPI Committee. It is also beneficial to teach staff to recognize IPC concerns and feel empowered to report them to IPC leaders.
Once concerns have been identified, teams should develop action plans to correct the IPC deficiencies. For ongoing surveillance and quality improvement, work with your teams to adopt a proactive culture that ties cleanliness to patient safety and quality of care.
