Tool for Assessing a Surveillance Program
In the Ambulatory Surgery Care (ASC) Setting*
Recommended Practices
Recommended Practices
Examples of Compliance
I. Risk Assessment: The surveillance system should be
based on an evaluation of the populations served:
 Types of patients/clients served
 Most common diagnoses
 Types of surgical or other invasive procedures
performed
 Risks of infection for procedures and treatments
performed
 Which patients are at risk for infection
 Diseases in the community and region
1. The ASC conducts an annual risk assessment and
documents findings. Some findings include:
 ASC is a privately-owned facility, not associated
with a local hospital, located in a small town
(population 10,0000)
 ASC serves both adult and pediatric patients
 The most common procedures performed are: lens
and cataract procedures, laparoscopic
cholecystectomy, laminectomy, inguinal and femoral
hernia repair, and tonsillectomy and/or
adenoidectomy
 Many procedures involve the use of scopes
 MRSA occurs often in the community and area
healthcare facilities
.
 ASC conducts surveillance for surgical site infections
(SSI) related to lens and cataract procedures,
laminectomy, inguinal and femoral hernia repair, and
tonsillectomy and/or adenoidectomy
 ASC refers to CMS, State, and accrediting agency
requirements when selecting indicators (events) to
monitor
 ASC monitors compliance with hand hygiene, safe
injection/medication practices and scope processing
protocols (including cleaning, disinfections, storage)
 ASC monitors all culture reports for MRSA
 ASC conducts surveillance for diseases reportable to
the State Health Department
II. Selecting the indicators (events) to monitor:
A. Outcome or process indicators selected should
have an important impact on the population
served.
B. Selection of indicators to be monitored should
occur in conjunction with the population
assessment.
C. Review regulatory or accrediting agency
requirements when selecting outcome or process
indicators for surveillance.
III. Using surveillance definitions: All data elements
should be clearly defined.
In its Surveillance Plan, the ASC delineates the data it
collects to identify SSIs related to the procedures
monitored. The Surveillance Program uses CDC National
Healthcare Safety Network (NHSN) methodology and
Facility Evidence of Compliance
Recommended Practices
Recommended Practices
Examples of Compliance
surveillance definitions as criteria for categorizing an
infection.1
IV. Collecting surveillance data:
A. Data collection process should be managed by
knowledgeable professionals.
B. Data should be collected consistently.
C. Appropriate information sources should be
available.
D. Appropriate tools should be used to collect data.
E. Appropriate post-discharge surveillance should be
used.
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The Infection Preventionist (IP) has attended an
infection prevention and control training course that
included instructions on how to conduct surveillance.
Surveillance data has been collected by a trained IP
using the same methodology for over 12 months.
A standardized data collection form is used for each
surveillance indicator.
Laboratory reports, physician reports, patient charts,
and electronic medical records are used when
collecting surveillance data.
The IP uses a personal computer to collect, store and
manage data.
ASC surgeons are required to complete a post
discharge SSI surveillance program form and return to
IC department
The same person collects surveillance data using a
standardized data collection form. If that person is out
of work for a prolonged period (such as a 2-week
vacation), a mechanism is developed to obtain
accurate surveillance data during that period.
V. Calculating and analyzing data:
A. Rates should be used when numerically measuring
an outcome or process.
B. Appropriate calculations should be used and
reported.
C. Consistent methodology should be used over time.
D. All aspects of surveillance must be equivalent in
order to compare rates over time within an
institution or between institutions.
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VI. Applying risk stratification methodology: A risk
stratification method should be used.
 For some rates, risk stratification is not possible.
 If rates are stratified, assure that subpopulation sizes
are large enough to be statistically meaningful
CDC NHSN risk stratification is used for SSI surveillance1
(i.e., a record on every patient undergoing a monitored
NHSN operative procedure is generated that includes the
data required in the NHSN Manual)
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Surveillance program uses rates (not raw numbers) to
measure and compare SSIs and other events monitored
over time.
IP uses appropriate methodology, numerators, and
denominators for calculating rates.1,2
To ensure consistent surveillance data, the IP uses
standardized data collection forms and CDC NHSN
definitions and methodology.1
Facility Evidence of Compliance
Recommended Practices
Recommended Practices
Examples of Compliance
VII. Reporting and using surveillance information:
A. There should be a plan for the distribution of
surveillance information.
B. Surveillance results should be reported to those
who are most able to impact and improve patient
care.
C. Reporting should be done on a systematic,
ongoing basis.
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Facility Evidence of Compliance
A written Annual Surveillance Plan describes the
persons and committees to whom surveillance reports
are distributed.
Surveillance findings are reported to the Quality
Assurance/Performance Improvement Committee
(QAPI)
Reports on SSIs and compliance with safe injection
and hand hygiene protocols are distributed quarterly to
the Medical Director and QAPI.
Essential Elements
Essential Elements
Examples of Compliance
A written plan should serve as the foundation of the
surveillance program.
The ASC has a surveillance plan that is based on the
populations(s) served and services provided. The plan
includes:
 a brief description of the facility
 a description of the types of services provided and the
population (s) served
 the objectives of the infection surveillance program
 a description of the surveillance indicators used
 the methodology for data collection
(e.g., total or targeted; sources of information; use of a
standardized data collection form)
 the methodology for calculating rates
 a description of the surveillance definitions used
 the types of surveillance reports, and how often and to
whom they are distributed
 the process for evaluating the effectiveness of the
program
CDC NHSN definitions are routinely used.1
IP consistently uses NHSN methodology (including
numerators and denominators specified by the CDC) for
calculating SSIs.1
The IP is a healthcare professional who has taken a
training course provided by APIC.
The IP understands epidemiologic principles and
Surveillance definitions and rate calculations are applied
consistently over time.
Personnel resources need to be appropriate for the type of
surveillance being performed.
Facility Evidence of Compliance
Essential Elements
Essential Elements
Other essential resources, such as computer support,
information and technology services, clerical services, and
administrative understanding and support are available.
The surveillance program (including surveillance
processes and data), as part of the overall infection
prevention and control program, should be evaluated at
least annually. Evaluation methods may include
qualitative assessments, but should also be based on
quantitative changes (e.g., improvements or decline in
rates).
Examples of Compliance
Facility Evidence of Compliance
surveillance techniques.
 The IP has a personal computer linked to the ASC’s
computer system and the Internet.
 The IP has access to clerical help.
 The Medical Director ensures that the IP has the
necessary resources to manage the program in
accordance with CMS, state and accrediting agency
requirements.
The ASC’s Annual QAPI Report outlines the findings of
the annual evaluation of the IC Surveillance Program
including the indicators measured and results of
performance improvement activities related to infection
prevention.
Recommended practices and essential elements based on: Lee TB et al. Recommended Practices for Surveillance: Association for Professionals in Infection Control and
Epidemiology. Am J Infect Control 2007;35:427-40 (available on APIC website)
1.
2.
CDC National Healthcare Safety Network (NHSN) Manual: Patient Safety Component Protocols available at: http://www.cdc.gov/nhsn
Lee T et al. Recommended Practices for Surveillance: APIC. Am J Infect Control 2007;35:427-40 (available on APIC website)
Tool adapted from “Tool for Assessing a Surveillance Program” in Arias K. Surveillance Programs in Healthcare Settings. 2nd ed. Association for Professionals in Infection
Control and Epidemiology, Inc: Washington, DC. 2009
Updated Feb 2014