ASC Infection Prevention & Control Consulting

ASC Infection Prevention & Control Consulting

The ambulatory surgical setting presents specific infection prevention challenges that differ from both hospital and outpatient clinic settings. The volume and turnover of surgical cases in an ASC creates opportunities for sterilization failures, inadequate room turnover between cases, and environmental contamination that would not exist in lower-volume settings. The use of implants — particularly orthopedic, spine, and ophthalmologic implants — creates specific infection risks that require specialized prevention protocols. And the movement of patients rapidly through pre-operative, intraoperative, and post-operative spaces within a single facility creates cross-contamination risks that require careful facility flow management.

CMS and all major accrediting organizations place significant emphasis on ASC infection control during surveys — and infection control deficiencies are among the most commonly cited findings in ASC surveys nationally. Sterilization and high-level disinfection (HLD) compliance in particular has been the subject of sustained CMS and accreditor focus, following high-profile ASC infection outbreaks traced to sterilization failures.

Service Areas

• Governing Body Structure & Compliance — Assessment and design of ASC governing body structure in accordance with CMS Conditions for Coverage, including board composition, meeting cadence, documentation standards, and delegation of authority to the administrator to ensure effective operational and quality oversight

• Medical Staff Bylaws Development & Review — Development and revision of ASC medical staff bylaws to ensure alignment with CMS requirements, accreditation standards, and applicable state law, while establishing clear processes for appointment, reappointment, and clinical privilege delineation

• Credentialing & Privileging System Design — Design of comprehensive credentialing and privileging workflows that include primary source verification, National Practitioner Data Bank checks, peer references, competency evaluation, and structured clinical privilege assignment to ensure compliance and patient safety

• Focused Professional Practice Evaluation (FPPE) — Development of structured FPPE programs for new or underperforming practitioners, including defined evaluation criteria, reviewer assignment, timelines, and documented outcomes to support privileging decisions

• Ongoing Professional Practice Evaluation (OPPE) — Design of continuous practitioner performance monitoring systems using ASC-relevant clinical data such as outcomes, complications, peer review findings, and protocol compliance to support ongoing privileging decisions and quality oversight

• Physician Governance in Joint Venture ASCs — Development of governance frameworks for joint venture ASCs that align hospital and physician stakeholder interests, while ensuring compliance with regulatory requirements and managing physician financial relationships consistent with Stark Law considerations