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Lessons from an infection control survey apply to you, too


May 1, 2008

Below are some infection control survey tips that tie into EC concerns or have similar implications between infection control and safety.

These tips come from Margaret Price, PhD, CIC, director of infection control and occupational health at St. Luke’s Episcopal Health in Houston, based on her experiences during a Joint Commission survey in 2008:
  • Ensure facility cleanliness—Surveyors focused heavily on how clean the hospital was, says Price. Make sure you have good systems in place in this area. One aspect to monitor is the cleaning and disinfection of portable medical equipment. Establish systems to identify how, when, and where staff members will clean the units to prevent lapses.
  • Examine your processes and look for potential holes—The most common scenario is that a staff member runs into a problem and deviates from what’s written in a policy. It may be a well-intentioned or harmless mistake, but that little deviation could spell big trouble. Avoid this scenario by encouraging collaboration and communication among departments. When a concern does arise, those involved can work together to solve the problem, rather than having individuals try to adapt processes on their own. Never assume staff members are following your policies. Confirm it periodically with spot checks.
  • Rehearse with staff members—Even the most competent and knowledgeable staff member can become nervous when approached by a surveyor. Have employees role-play, write scripts, or otherwise practice explaining how the department implements management programs, so they can respond capably when called upon.
  • Make sure your meeting minutes are up to date—At St. Luke’s, the surveyors reviewed a year’s worth of infection control committee meeting minutes and appeared to look at them in great detail. It’s critical to ensure that if an issue is discussed in one set of minutes, the next sets of minutes detail the decisions that were made regarding that issue and the steps taken to follow up, Price says. It is also a good idea to document in the minutes when your hospital successfully resolves an issue.

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