Excellentia Advisory Group
ImPaCTInfection Prevention and Control Trends for ASC's 
In This Issue
About the Author
This Month's Training Opportunities
Hot Topics
CMS Quality Reporting Specifications Release
Antibiotic Stewardship Coming
Critter Craze
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Robin Novak, RN, CIC
Director of Infection Prevention

636.875.5088 ext. 101
This Month's Training Opportunities
Building Antibiotic Stewardship into the ASC Setting

Root Cause Analysis

Emergency Preparedness Rule / Emergency Operations Plan

Over 70 Infection Prevention
 topics/presentations available in our library.
Word On the Street
CMS has issued requirements to reduce Legionella risk in healthcare facility water systems.  Not directed toward ASC - yet.  
Clindamycin injection recall due to lack of sterility assurance:  

Hospira recalls Sodium bicarbonate injection, succinylcholine due to microbial growth.

Volume 1, Number 9
July 2017

Have you ever had an event occur that you really needed to get to the root cause, but you just were certain of the process?  Is root cause analysis only used for sentinel events at your facility?  As leaders, director of nurses, quality coordinators and even infection preventionist, at some point in our career an unfavorable event will happen.  It will be our responsibility to assess, investigate, interview, brainstorm, inspire, collaborate, coordinate and make recommendations to prevent recurrence. 

The July webinar will help you do just that!  This will be an interactive session and you will walk away with a completed tool to use as an example for your future needs.  Be sure to sign up for my July 12 live webinar or you can order the presentation on view upon demand.

Registered Nurse, Certified Infection Preventionist dedicated to disease prevention and high quality healthcare.  Strong decision maker who understands the importance of patient, visitor and staff safety following evidence based best practices.
Driven and compassionate healthcare professional with 30 years hands-on experience in fast-paced ambulatory surgery center and hospital environments.  Accountable and responsible with an additional focus on Quality Assurance Process Improvement .
In the past, Robin has served as the SGNA Carolina Chapter President, involved in SGNA Practice Committee as well as a Regional Committee member.  Robin has been active with APIC and is a current member of APIC PALMETTO. Robin was prior employed at the Ambulatory Surgery Center of Spartanburg since 2004 and held roles of Endoscopy Nurse, Endoscopy Charge Nurse and most recently the Quality Assurance Process Improvement Coordinator.  Robin has worked on several infection prevention projects for Excellentia Advisory Group including a key role as a faculty speaker at our annual Infection Prevention Strategies for ASC's conference in Las Vegas.  Robin is now Excellentia's Director of Infection Prevention & Endoscopy.
CMS Quality Reporting Specifications Release
By Robin O. Novak, RN, CIC

CMS released notes on June 1, 2017 called Ambulatory Surgical Center Quality Reporting Specifications Manual, Release Notes Version 7.0.

In this release, two new measures were added:
  • ASC-13: Normothermia
  • ASC-14: Unplanned Anterior Vitrectomy

Measure ID#: ASC-13 Normothermia can be found on pages 39 - 41 of this document. Unplanned anterior vitrectomy is found on pages 42 - 43.
CLICK HERE for this publication.      

If you need to  know more about Normothermia, we have a 1 hour presentation in view-upon-demand available. CLICK HERE      

Antibiotic Stewardship Program Update
By Robin Novak, RN, CIC

Antimicrobial/ antibiotic stewardship is now a proposed and finalized measure for hospitals and long term care facilities.  In some states, the requirement to have an antimicrobial/ antibiotic stewardship program has trickled down to ASC's.  Do you know the reason why having a antimicrobial/ antibiotic stewardship program is so important?  Do you know where to start?  If you think it doesn't matter, if you think it will never be required, make no mistake...  changes are on the horizon and ASC leadership and infection preventionists must be on their game to meet expectations.  Missouri is one of those states that now require ASC's to have such a program and the deadline is Aug. 28, 2017 so now is the time to get yours together!

Take this opportunity to learn more and make proactive changes to launch your ASC as a leader among ASC's.  CLICK HERE to learn more from the CDC.  As always, you can expect Excellentia to put together a presentation to cover this program in a simple to use and understand format.    CLICK HERE for webinar presentation.

Critter Craze
By Robin O. Novak, RN, CIC
Who am I? -
  • I present with anorexia, malaise, myalgia, headache and fever.  Abdominal pain and diarrhea are also common
  • I am characterized by pneumonia and a non-productive cough
  • I can be quite severe and progress to respiratory failure
  • I am a gram negative bacilli and a water borne disease
  • Outbreaks are more common in summer and autumn.
  • The incubation period is 2-10 days, but most often 5-6 days.
  • Transmission is airborne
  • I was discovered in 1976 after an outbreak at a convention in Philadelphia.
  • My reservoir is man- made water supplies that aerosolize water
  • Prevention includes proper maintenance and disinfection of water supplies.
Email Robin at robin@excellentiagroup.com  
with your response.  You will receive a personalized reply with validation of the correct answer.

If you are in need of assistance with your infection prevention program, Robin will be able to assist with everything from setting up your program, training your Infection Preventionist, writing or editing Policies & Procedures or just simple telephonic consultation.  Robin is taking on-site requests for 2017 at this time.  Secure a date on her calendar now.

Please let us know how we can help.

Cathy Montgomery, RN, CASC                Robin Novak, RN, CIC
636-875-5088 extension 102                    636-875-5088 ext. 101

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