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Ambulatory Buzz

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Information on all things ambulatory from The Joint Commission

Infection Control Program Elements to Remember

Mar 07, 2018 | Comments (0) | 4716 Views

Crissy BenzeBy Crissy Benze, MSN, BSN, RN
Senior Consultant
Progressive Surgical Solutions

As busy Clinical Directors and Infection Control Coordinators, constant attention is required to ensure our ambulatory surgery center (ASC) policies and procedures for infection control (IC) are kept up-to-date.

Though IC is incorporated into ASCs required Quality Assessment and Performance Improvement (QAPI) programs for Medicare, and we work to ensure that all ambulatory care staff remain compliant, there are still some commonly overlooked elements of IC programs.

Standard Precautions
First and foremost is to ensure that ALL ambulatory care medical and facility staff members understand the concept of Standard Precautions, which are designed to reduce the risk of transmission from both recognized and unrecognized sources of infection. Standard Precautions apply to all patients regardless of their diagnosis or suspected infection status. The basic rule of thumb is to consider all your patients as ‘infected’ and treat them with the highest level of precaution. 

 Standard Precautions include the following:

  • hand hygiene

  • personal protective equipment (PPE)

  • safe injection practices

  • personnel safety

  • patient placement

  • patient care equipment

  • care of the environment

  • laundry 


Staging the OR
With Standard Precautions practices in mind, there should be only minimal supplies actually kept in the operating room (OR). Any supplies maintained in the OR should be stored in cabinets and drawers or covered carts. Supplies for subsequent patients should be kept covered and not exposed until the time of surgery. 

Timing must be just as precise with regard to cleaning. As a general rule, ORs must be cleaned between each surgical patient, but the cleaning should not start until the previous patient and soiled instruments leave the room. The next patient should not enter the OR until it is cleaned, per facility protocol. 

Finally, we must adhere to specific traffic patterns in the surgical suite. The ASC’s space planning and layout was created with these traffic patterns in mind. There are three designated areas, defined by the activities performed in each one:

  • restricted

  • semi-restricted

  • unrestricted areas

Restricted areas include ORs and other procedural areas in which operative or other invasive procedures are performed. Medical and facility staff in restricted areas must wear appropriate surgical attire, including hair covering. Masks must be worn and the doors should be opened minimally when sterile supplies are open. 

It is easy sometimes to be focused on the big elements of our facility IC programs, but it is so important to not forget the less obvious protections. This can mean the difference between a positive patient outcome and a post-op infection. Hand hygiene, PPE, safe injection practices, traffic patterns, and more are all key elements! 

A great place to keep abreast of the latest developments impacting ambulatory care Infection Control and Prevention issues is The Joint Commission’s Healthcare Acquired Infections Portal.


Crissy Benze, MSN, RN, works with ASCs on regulatory compliance audits, accreditation preparation, best practices analysis, efficiency studies, licensing and certification preparation, and management services. Prior to her current position, she worked as a trauma ICU and OR nurse.

AHRQ Focuses on ASC Patient Safety Resources

Feb 23, 2018 | Comments (0) | 993 Views

18.Castro_PhotoBy Gerry Castro
Project Director, Office of Patient Safety
The Joint Commission

Despite the trend of more surgical care being provided in ambulatory care settings, the majority of patient safety efforts to date have focused on the inpatient setting. The Agency for Healthcare Research and Quality (AHRQ) is addressing that gap with several valuable resources for ambulatory surgery centers (ASCs). 

First, in response to requests from ASCs, AHRQ developed the ASC Survey On Patient Safety Culture, a 27-question evaluation addressing patient communications about:

  • patient information

  • staff communication

  • work pressures

  • teamwork

  • training

  • organizational learning

  • responding to mistakes

  • support for patient safety


The AHRQ survey tool includes survey forms in both English and Spanish, a user guide, and an action planning tool for using the results of the survey. The survey takes about 10 minutes to complete. Once results are analyzed, an ASC can identify potential areas for improvement and implement an action plan based on organizational quality and safety expectations.

Engaging Patients 

Involving patients, families, and other ambulatory caregivers as part of the ASC care team is an important strategy for improving patient safety as championed by both the AHRQ and The Joint Commission. Making sure everyone on the surgical team knows what is happening and what to expect is essential to a safe and successful surgical procedure.  

To help engage patients in their care, another free resource available from AHRQ is an ASC-specific patient brochure called “Getting Ready for Your Ambulatory Surgery”, which walks the surgical patient through preparing for surgery, what to expect on the day of surgery, and what to expect post-surgery.


Safety Culture – A Crucial Foundation

Ideally, patients should be engaged in the ASCs patient safety culture. This is considered a prerequisite for an ASC to ensure the organization provides safe, effective patient care.  What is a strong safety culture? It is the driving principle behind an organization’s commitment to high quality and patient safety and it encompasses:

  • individual and group beliefs

  • values

  • attitudes

  • perceptions

  • competencies

  • patterns of behavior

Joint Commission standard LD.03.01.01 states: “Leaders create and maintain a culture of safety and quality throughout the practice.”  Accountable leadership is required to:

  • foster trust

  • identify unsafe conditions

  • strengthen systems and processes

  • assess safe operations.

The AHRQ ASC Survey on Patient Safety Culture is an excellent instrument to assist in establishing a baseline measure of an ambulatory organization’s safety culture.

Patient safety culture and patient engagement are only two components of your ASC’s patient safety system.  For additional information on other important elements of a patient safety system and the standards that support them, take a look back at our Jan. 2017 AmBuzz.

Gerard M. Castro, PhD, MPH is the Project Director for Patient Safety Initiatives in the Office of Patient Safety at The Joint Commission. Castro was the Principal Investigator for the Office of the National Coordinator for Health IT projects. He is also a member of the AAMI Foundation Board of Directors, the NQF Common Formats and HIT Patient Safety and Expert Panels, as well as the HTSI Coalition of Organizations for Reporting Adverse Events (CORE) Committee.

Hand Hygiene Compliance Now Mandatory in All Ambulatory Care Settings

Feb 08, 2018 | Comments (0) | 4592 Views

By Mary Brockway 

Director, Clinical Research 

Department of Standards and Survey Methods 

brockway_picA decade ago, The Joint Commission began requiring health care organizations to maintain a hand hygiene program. For the past several years, deemed ambulatory surgery center (ASC) surveyors have cited hand hygiene as an expectation of the Centers for Medicare and Medicaid Services (CMS). Starting this year, ambulatory care surveyors will issue a citation if they witness any ambulatory care organization employee failing to follow correct hand hygiene guidelines before providing direct patient care. 

Reality of Complying 

By now, we all know that hands are the major pathway for germ transmission in all health care settings.  

Ensuring clinician and staff hand hygiene before and after every patient contact reduces the risk of acquiring an infection in a health care setting. Unfortunately, the Centers for Disease Control and Prevention (CDC) estimates that—on average—healthcare providers follow hand hygiene guidelines less than half as often as they should.  

That doesn’t mean that staff are not taking the responsibility seriously. After all, healthcare providers may have to wash their hands or use alcohol-based hand sanitizers upwards of 100 times per shift, depending on their organization’s patient volume.      


Deficiency Risk 

Regardless of how many previous times in a day an ambulatory care provider may have followed their hand hygiene guidelines, if a surveyor notices an individual skip the hand hygiene step, it can result in a deficiency resulting in a Requirement for Improvement (RFI) under Infection Prevention and Control (IC) Standard IC.02.01.01, EP 2: “The [organization] uses standard precautions, including the use of personal protective equipment, to reduce the risk of infection.” 


Additionally, organizations must do their part to demonstrate compliance with the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) hand hygiene guidelines. According to Dana Dunn, Joint Commission ambulatory care field director, “our surveyors will continue assessing the organization’s hand hygiene program compliance with National Patient Safety Goal NPSG.07.01.10, demonstrating they comply with CDC or WHO hand hygiene guidelines.” 

There’s an App for That

For many years, The Joint Commission Center for Transforming Healthcare has offered the Hand Hygiene Targeted Solutions Tool (TST)® for accredited organizations, providing the technology to measure performance and identify barriers to improving and sustaining hand hygiene compliance.  

Now, the TST® tool is available as an app from the Apple or Google Play Store to electronically track your organization’s hand hygiene compliance. With the ability to record hand hygiene observations on any smartphone or tablet, TST® Hand Hygiene users can now enter project data observations in real time.  

If you’re more comfortable with the tried-and-true paper form, that’s still an acceptable process. The method you use to improve hand hygiene compliance in your organization is your choice, but do make sure every employee is following your chosen hand hygiene policy. If you’d like to learn more about hand hygiene, the December 2017 issue of Perspectives offers a helpful summary on this important infection prevention topic.  

Mary Brockway is director of clinical research and standards at The Joint Commission. Prior to joining the enterprise, she was manager of clinical operations at Advocate Health Care in the greater Chicago area. 


Joint Commission Accreditation – A Team-Building Journey for Your Community Health Center

Jan 25, 2018 | Comments (0) | 485 Views

Pam_KomperdaBy Pam Komperda
Project Manager
Community Health Center Accreditation

The journey to achieve The Joint Commission’s ambulatory care accreditation is a process that can promote high quality and improve both patient safety and healthcare outcomes for your Community Health Center. It’s a process that is best accomplished by engaging all your center’s staff in the journey, including your executive leadership team and board members.

Successful community health centers embark on and complete the accreditation journey as a team. To successfully achieve accreditation your center should consider:

  • selecting a key individual to be your accreditation champion

  • involving all staff at all levels in your health center’s quality improvement efforts

  • organizing accreditation compliance committees

  • hosting regular report-out sessions on data outcomes of compliance activities during staff meetings

  • implementing daily and/or monthly checklists or tracking tools in your high risk areas

  • conducting mock surveys/patient and system tracers on a regular basis


Taking on Challenges

Identifying risk in your health center is also key to continuous compliance. The top challenging standards compliance areas for community health centers are currently related to infection prevention and control and medication management.  The top five non-compliant standards areas are:


Helpful Resources

The ambulatory care program has many resources and tools available to guide and support your community health center through the accreditation journey, including Standards BoosterPaks, the Leading Practice Library tool, and Educational Teleconference Sessions regarding standards-related topics and the accreditation process.  

The Joint Commission’s Intracycle Monitoring (ICM) process is another valuable resource. ICM will assist your center in identifying areas of noncompliance and support your ongoing quality monitoring efforts throughout the three-year accreditation cycle. Benefits of the ICM process include:            

  • identification of high-risk areas and related standards 

  • detection of critical systems/processes that could lead to adverse effects if they become weak or fail

  • individualized conference call with Standards Interpretation staff to discuss the high risk areas identified by your health center 

Strong leadership and staff engagement throughout the accreditation process will ensure your Team stays on track to successfully complete the ambulatory care accreditation journey. 

Do you have tips for Community Health Centers seeking accreditation? Tell me about your journey at

Pam Komperda is the project manager of the community health center accreditation program for The Joint Commission. In this role, her focus is to lead and support Joint Commission activities related to the contract for accreditation services for health centers funded by the Federal Health Resources and Services Administration’s (HRSA) Bureau of Primary Health Care (BPHC).  She holds the key role of the in-house advocate for the Bureau of Primary Health Care and the health centers supported by the BPHC.

Best of AmBuzz for 2017

Jan 10, 2018 | Comments (0) | 627 Views

By Michael Kulczycki
Executive Director, Ambulatory Health Care

2017 was a year filled with important health care events and issues impacting the ambulatory care community, many of which were covered in Ambulatory Buzz… our very own informational ambulatory care blog. So, as 2017 transitions into the pages of the health care history books, let’s take a quick look back via a sampling of your favorite ambulatory care topics (based on number of “views”) posted on AmBuzz:


Top 10 Challenging Standards 
It’s always interesting to see how often, year-to-year, certain Joint Commission standards create compliance challenges for our ambulatory care (AHC) and office-based surgery (OBS) customers. Take a look back at the most commonly cited non-compliant AHC & OBS standards for 2016 – addressed by our Joint Commission standards experts – and you’ll be better prepared for the year ahead. 

Improve Your Center’s Infection Control & Prevention Processes
The Joint Commission’s ambulatory care program convenes an industry conference each year, bringing together our varied ambulatory care customers and standards experts. In 2017, Lisa Waldowski, Joint Commission’s infection control specialist, provided a thorough overview of critical infection prevention and control issues, essentially important to all ambulatory health care settings.

An ASC Administrator's View of the On-Site Survey
AmBuzz readers are always interested in other customer viewpoints. Last year, Raquel Rios, administrator of Crystal Run Surgery Center, shared her organization’s experience with the Joint Commission’s on-site survey process for an ASC, and why her organization found it a truly rewarding event. 

Patient Safety Systems Chapter for Ambulatory Care and Office-Based Surgery 
Although the “Patient Safety Systems” (PS) chapter does not contain any new standards or requirements, the PS chapter – first introduced in 2017 -- does describe how ambulatory care organizations (AHC) and office-based surgery (OBS) practices can apply existing Joint Commission requirements to support a strong and fully integrated patient safety system.

Five Things You Need to Know About 2017 Survey Changes for Medicare Deemed ASCs
These new changes impacted about two-thirds of Joint Commission accredited ambulatory care surgery centers (ASCs) choosing to use the Medicare deemed option to achieve accreditation. AmBuzz gave a ‘heads-up’ to ASC organizations that the changes might call for a larger time commitment from ASC leaders and staff, but noted the new processes would also add educational value to the survey process. 

Keys to Better Environment of Care Compliance with EC.02.06.01 – Part 1
Keys to Better Environment of Care Compliance with EC.02.06.01 – Part 2

This final selection from your list of favorite AmBuzz postings is actually a two-parter, providing a wealth of insights from Joint Commission staff engineer Kathy Tolomeo. There’s no doubt the environment of your health care facility is a critical component of your organization; after all, both your patients and your staff occupy this special space a good part of their day… so look back and learn!

2018 is marching forward and your AmBuzz will continue to address important health care issues and concerns relevant to you – our much-appreciated ambulatory and office-based surgery customers. If you’d like to contribute to AmBuzz, I encourage you to contact me at

Michael Kulczycki, MBA, CAE is the executive director for the Ambulatory Care Accreditation Program at The Joint Commission. Kulczycki has over 40 years of experience in managing and marketing health care organizations and other entities, previously serving as CEO of The Alliance for Healthcare Strategy and Marketing, Chicago; executive director of the Illinois Home Care Council, Chicago; and in a variety of senior healthcare association positions. Kulczycki was awarded an ASAE Fellow status (FASAE) by the American Society of Association Executives. In 2014, he was inducted as fellow member of the Institute of Medicine Chicago.

Kulczycki holds a master’s degree in business administration from the Kellogg School of Management of Northwestern University, Evanston, IL and earned his undergraduate degree in communications from Notre Dame, South Bend, IN.