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M A R C H 2 0 1 5 | O U T P A T I E N TS U R G E R Y. N E T
Gain support from leadership and decide who'll oversee the pro-
gram. This is crucial. Make leadership aware that CMS
Conditions for Coverage require facilities to:
• maintain an infection control program that seeks to minimize
infections and communicable diseases;
• designate a dedicated individual with infection control training to
direct the program and activities; and
• have a mechanism in place to immediately implement corrective
actions and preventive
measures.
In our case, the director of nursing, the director of the ASC and the
director of clinics went to our CEO and asked for — and got — the
support we needed.
Decide what types of cases you're going to do SSI surveillance
on and how you're going to do it. There are many ways to go
about it. We track every procedure. Some monitor specific problem
cases — for example, total hips, or all foot and hand cases, because
those seem to be more prone to post-op infections. If you don't have
time or resources to do every single case, you might decide to pull
random cases, say, one of every 10. You can get the information you
need by checking post-op notes or by e-mailing physicians and asking
for reports on patients who've had surgery that month. Facilities with
EMRs may also be able to create reports to enhance SSI detection,
such as weekly culture reports and/or hospital readmission reports.
Develop a risk assessment and plan. It's important to document
your goals, the strategies you'll implement to meet them, your
evaluation methods and your progress. Again, make sure leadership is
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