Center for Improvement in Healthcare Quality Newsletter
December 2021

News You Can Use

Holiday Message

It’s traditional this time of year to talk about giving thanks and offering best wishes to one and all. It’s a fair question to ask whether there is anything to be thankful for? Our nation is in turmoil. Forces are trying to drive us apart rather than bring us together. After two years of battling a pandemic - we’re simply exhausted. And if all this wasn’t enough, have you seen your grocery bill lately!
It’s tempting – and understandable – to not quite have that “holiday cheer” this year. But I would like to suggest that we still have a lot to be thankful for. Our family, our friends, and – as importantly – each other. As healthcare workers you share a bond that is both unmistakable and unbreakable.
You fight the good fight. You risk your own health and safety for the sake of helping others. You’re the brave few that care for those in their most dire time of need. You celebrate the victory and mourn the loss. Yes, as far as I’m concerned, each of you are truly heroes.
So, this holiday season I do give thanks. I give thanks for the honor and privilege of working with each of you in our collective mission to improve the lives of the people we touch. My sincere wish is that this holiday season brings you and your loved one’s joy, peace, and good health.
-Rick Curtis, CEO
Center for Improvement in Healthcare Quality

December Compliance Tip of the Month

December’s tip of the month is focused on the standard/requirements regarding the Provision of Operative & Invasive Services. Specifically, appropriate “terminal cleaning”.
Organizations can be cited by surveyors when they are unable to demonstrate the terminal cleaning of surgical suites and procedure areas/rooms. AORN (Association of periOperative Registered Nurses) is leading recommending agency and has published guidelines and makes them available to their members/subscribers.
The requirement for terminal cleaning by AORN says:
  • Terminally clean operating and procedure rooms each day the rooms are used.
  • Clean and disinfect the exposed surfaces, including wheels and casters, of all items:
    • anesthesia carts, including the top and drawer handles
    • anesthesia equipment
    • anesthesia machines, including dials, knobs, and valves
    • patient monitors, including cables
    • OR beds
    • reusable table straps
    • OR bed attachments
    • positioning devices
    • patient transfer devices
    • overhead procedure lights
    • tables and Mayo stands
    • mobile and fixed equipment
    • storage cabinets, supply carts, and furniture
    • light switches
    • door handles and push plates
    • telephones and mobile communication devices
    • computer accessories (e.g., keyboards, mouse, touch screen)
    • chairs, stools, and step stools
    • trash and linen receptacles
  • Clean and disinfect the entire floor, including areas under the OR bed and mobile equipment, using either a wet vacuum or mop.
Terminal cleaning is thorough environmental cleaning performed at the end of each day the room or area is used. It is not necessary to perform terminal cleaning or close the OR after a contaminated or dirty/infected procedure (ie, Class III, Class IV). Enhanced environmental cleaning should be performed If the patient is infected with a multidrug-resistant organism (MDRO).
Both the CMS and CIHQ standards/requirements have been included for reference.


OI-1: Provision of Operative & Invasive Services
If the organization provides operative or invasive services, it must do so in a safe manner and within accepted standards of care.
  1. The organization must develop and implement processes to assure the following:
    • Access to operative, invasive and recovery areas is limited to authorized personnel and that the traffic flow pattern adheres to accepted standards of practice;
      • The conformance to aseptic and sterile technique by all individuals involved in operative and invasive procedures;
      • Appropriate cleaning between cases and appropriate terminal cleaning applied;
      • Donning of attire appropriate for the kind of operative or invasive procedure performed;
      • That equipment is available for rapid and routine sterilization of equipment, supplies and instrumentation;
      • That sterilized materials are packaged, handled, labeled and stored in a manner that ensures sterility;
      • That temperature and humidity of operative suites are monitored and maintained within accepted standards of practice.


§482.51(b) Standard: Delivery of Service
Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. Interpretive Guidelines §482.51(b)
Policies governing surgical care should contain:
  • Aseptic and sterile surveillance and practice, including scrub techniques;
  • Identification of infected and non-infected cases;
  • Housekeeping requirements/procedures;
  • Patient care requirements:
    • Preoperative work-up;
    • Patient consents and releases;
    • Clinical procedures;
    • Safety practices;
    • Patient identification procedures;
  • Duties of scrub and circulating nurse;
  • Safety practices;
  • The requirement to conduct surgical counts in accordance with accepted standards of practice;
  • Scheduling of patients for surgery;
  • Personnel policies unique to the O.R.;
  • Resuscitative techniques;
  • DNR status;
  • Care of surgical specimens;
  • Malignant hyperthermia;
  • Appropriate protocols for all surgical procedures performed. These may be procedure-specific or general in nature and will include a list of equipment, materials, and supplies necessary to properly carry out job assignment;
  • Sterilization and disinfection procedures;
  • Acceptable operating room attire;
  • Handling infections and biomedical/medical waste; and
  • Outpatient surgery post-operative care planning and coordination, and provisions for follow-up care.
Policies and procedures must be written, implemented, and enforced. Surgical services’ policies must be in accordance with acceptable standards of medical practice and surgical patient care.
It is recommended that the organization have a mechanism in place to document the terminal cleaning in order to demonstrate compliance to the regulations during a survey. There should also be a process in order to determine if the operative suite/procedure area or room is used on any given day. This will eliminate any question regarding compliance.
It is recommended that the organization have a policy/procedure that includes the process used to demonstrate compliance with all manufacturer instructions for use regarding the processing of hinged instruments. CIHQ as well as AAMI and AORN strongly recommend that a device be used to assure that they stay open such as instrument stringers, tip protectors or dual instrument guards.
ARS resources to assist with compliance:
Reference Library – Other Regulatory Reference Entities
  • AORN Fact Sheet – AORN Recommendations for Environmental Cleaning

A New Way to Achieve Healthcare Accreditation Certified Professional (HACP-CMS)

Becoming and maintaining HACP-CMS certification just got easier! It is the only certification based 100% in the CMS Conditions of Particpation.
Historically, candidates or existing HACP-CMS holders could attend the in person course/test administration which preceded the annual CIHQ Accreditation & Regulatory Summit each year or purchase the study guide and/or practice exam, study independently and then register and take the examination.
Technology is our friend and there is a new online video course. The course consists of 8 video classes in which you will be able to hear and see Rick Curtis as he teaches the regulations. Then you will be able to take the exam, achieve or renew certification and receive CEU’s. The study guide and practice exam are optional but are still available for purchase.
Regardless of you learning preferences, CIHQ-HACP has provided you with the tools to join the ranks of over 1000 HACP holders across our nation and abroad.
If you want to learn more just go to

CIHQ Sponsors NALTH and AMRPA Conferences

We would like to thank the National Association of Long-Term Hospitals (NALTH) and American Medical Rehabilitation Providers Association (AMRPA) for the opportunity to sponsor their virtual events.
NALTH leads the industry in advancing the health, well-being and understanding of patients who require a prolonged hospital stay and specialized programs of care to achieve medical stability and maximum function. They hosted a series of webinars, which included CIHQ’ own Rick Curtis speaking about Positioning the LTCH for Today’s Compliance Challenges.Learning objectives included identifying key learnings from the CMS annual report to Congress on accrediting organizations, the impact of COVID-19 on the survey and certification process, and current compliance challenges to key regulation. Congratulations to gift card winner Kelli Anderson of Madonna Rehabilitation Hospitals!
We value our collaboration and NALTH membership and look forward to attending the Spring 2022 event in Glendale, AZ.
AMRPA hosted their Fall Educational Conference & Expo in late October. AMRPA’s goal is to advance the field of medical rehabilitation through advocacy, education, and the promotion of access to care. Highlights from AMRPA include Rick Curtis’ Boot Camp presentation on QAPI. Congratulations to gift card winners Peggy Seminara, Program Director of Moss Rehab, and Joey Swiney of Knoxville Rehab Hospital.
We had great experiences with these virtual events and look forward to continued partnership. Did you catch Rick’s presentation at NALTH OR AMRPA? Send us a note and let us know what you thought.