Infection Prevention

Infection prevention is a topic that touches many areas in an ASC however the bottom line is patient safety through preventing infections.  The number one way to transmit infections is through touch. Improper hand washing or poor hand hygiene practices can lead to the transmission of microbes.   One of the greatest services you can provide your patient is to follow a strong hand hygiene program.  Be diligent with follow up and compliance.  This includes ALL providers (staff, allied healthcare and physicians).

The rule of thumb to remember is: if a patient is touched, hand hygiene should follow when leaving the point of care.  If an invasive procedure is performed, such as an IV start, perform hand hygiene before and after donning gloves.  We do not need to perform hand hygiene with every touch however, when we leave the patient’s bedside and travel elsewhere, hand hygiene is required.

As a center or patient care unit, provide your staff with the tools needed to succeed.  If they do not have alcohol based gels or sinks, there is a failure in the system.  Infection prevention is a team effort and it starts with the facility and ends with your client. Not only do you protect your patient, you also protect your healthcare team.

Life Safety Overview with Alex Bornemann

As many of you know, the national ASC Association Conference just recently took place in Washington DC. There were many extraordinary presentations, but the one by Bill Lindeman on Life Safety was perhaps the most important that we saw. Several recent surveys have shown that it is one of the most cited areas for ASCs. Therefore, without much more preamble we would like to share with you a bit of what we learned so we can better prepare you all for your surveys.

The Basics:

CMS Requires all ASCs to comply with the relevant codes in both NFPA 99 (Life Safety Code) and NFPA 101 (Health Care Facilities). The current version is the 2012 edition, which has been in place since 07/05/2016. July 5, 2016 is also the break off point for any mention of “existing” in the codes. Anything built or having all pertinent approvals prior is existing otherwise it is “new”.

When thinking about requirements for your facility, it is best to know what categories you fall under. For example, a few you should know off the top of your head are: “new” or “existing”, “sprinklered” or “Non-sprinklered”. If you have sprinklers, you have certain testing requirements, but you have fewer requirements when it comes to fire alarms. On the reverse side, if you have no sprinklers, then you need fire alarms in every room. Yes, even that very small closet. Alternatively, your facility may need to be built with fire proof structures if it is not sprinklered. Each case is different, but it is important to know which general categories you fall under, because they determine how far away you can have your exits, your testing schedules, and much more.

The New Risk Categories

There are now four Categories of Risk that you should get familiar with:

  • Category 1 – Facility Systems in which failure of such equipment of systems is likely to cause major injury or death to patients or caregivers
  • Category 2 – Facility Systems in which failure of such equipment of systems is likely to cause minor injury to patients or caregivers
  • Category 3 – Facility Systems in which failure of such equipment of systems is not likely to cause injury to patients or caregivers, but can cause discomfort for patients
  • Category 4 – Facility Systems in which failure of such equipment of systems would have no impact on patient care

Determine your risk using the ASHE Risk Assessment or another similar tool. These categories of risk will determine which requirements your facility will need to follow for your various systems and equipment.

Exit Basics

  • 2 exits minimum on each floor
  • Lit exit signs with one chevron to direct traffic to nearest exit especially when it is not clear where the closest exit is
  • “The clear width of any corridor or passageway required for exit access shall not be less than 44 inches.”- NFPA 101-219 At no time should anything including delivery boxes, laundry bags, chairs, stretchers, and storage infringe on that 44 inches in new and existing facilities.
  • Generally speaking, you are responsible for getting any person in your facility to a “Public Way” during an emergency. This basically means you need to light their way to the sidewalk outside your facility, of course each case is different as to what your “Public Way” will be.

You should know what types of areas each of your rooms is considered. Knowing these definitions will go a long way when it comes to determining compliance. Differences you want to know:

  • Wet vs Dry Rooms
  • What is on the generator vs what is on battery back up
  • Different storage rooms: Medical Gas, Hazardous, Sterile, Medication
  • Smoke Compartments and Fire Wall ratings
  • Areas of Refuge
  • Type of Essential Electrical System (EES) needed for which equipment
    • 1 or 2 – must last long enough to complete care and discharge all patients during emergency
    • 3 – must last 90 minutes or as long as needed for orderly cessation of procedures and evacuation (whichever is longer).
  • Rooms that are sprinklered and rooms that have smoke alarms

This is just some of what we learned, but there is so much more. Currently, we are investing resources into becoming even more proficient with these codes. Please feel free to ask questions or comment below or directly through email.


Welcome to the Ambulatory Healthcare Strategies Blog

As an ASC Leader, you must continuously make sure your ASC is ready for a Survey at any time.

Ambulatory Healthcare Strategies provides a unique business model – totally focused on what your organization needs – not a “cookie cutter” approach to outsources services.

Let’s Meet the Team!!

John Goehle, CEO, and the face of the company you have all come to know and love! John Goehle is one of the nation’s leading Ambulatory Surgery Center experts. He has written eight books on the industry, including “The Survey Guide for ASCs – A Guide to the CMS Conditions for Coverage and Interpretive Guidelines for Ambulatory Surgery Centers”. He is also a frequent speaker at ASC Conferences.

Alexander Bornemann, Director of Operations, making sure that the company’s day to day activities go smoothly and efficiently. He also has a specialty in financial reporting, and database management

Judie D’Ambrosio, Director of Education, creating Annual Education, New Employee Orientation, Monthly Inservice’s and retraining when necessary. She also specializes in Policy and Procedure Manual building and revising.

In addition, we have registered nursing staff and qualified administrative staff to assist when needed.

These are the people that have your back! This is the team that wants to see you succeed just as much as you do! Contact us for anything you may need, any advice we might be able to offer, and, of course, that tailored service that we are known for. And, be sure to check back here often for insights and advise that may help your day to day operations.

Feel free to contact Judie at