Prevent Adverse Outcomes Through Development of Infection Prevention and Quality Improvement Program

Helpful reminders that can help to ensure safe patient outcomes and reduce risk of infection in your healthcare facility

october 2021

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

Happy International Infection Prevention Week Oct 17-23, National Healthcare Quality Week Oct 17-23, National Health Education Week Oct 18-22, Respiratory Care Week Oct 24-30, Medical Ultrasound Awareness Month, National Breast Cancer Awareness Month and National Physical Therapy Month from HCE!


Infection Prevention Tips


Although we cannot say enough about the importance of good hand hygiene compliance, we can assure you that in general, compliance rates have gone up significantly throughout the course of the Covid-19 pandemic. This is truly something to celebrate! It is still critical to ensure that employees are well trained on proper hand hygiene technique, however. For instance, do staff understand when to wash their hands with soap and water vs. hand sanitizer? It seems simple, but we can assure you that when asking this question, you will get an even mix of responses.


Hand sanitizer is perfectly acceptable when performing most general duties. It is quick, requires very little activity and studies suggest that this method is 99.99% effective in preventing the spread of germs and infection. Be sure employees do understand that this is not an acceptable method of cleaning their hands when dealing with any blood or bodily fluids. The soap and water method are considered to be most effective when caring for patients who are on enteric isolation precautions. If your organization has a well trained Infection Preventionist on staff, then rest assured that there is a good chance that your employees are aware of which method to choose when providing day to day care to patients.


It is important to incorporate this training into your existing infection prevention program. This education should be done as a part of any new employee orientation as well as on an annual basis. Never assume that even your most seasoned healthcare team members understand which method to choose when incorporating best practice into their daily routine.


Healthcare Quality Improvement Tips 


Proper identification of a patient would seem to most a simplistic of tasks for most employees to be able to complete. This continues to be a point of focus with regulatory agencies because of the inconsistencies in methods used to obtain proper identification of patients. Incorrect identification of a patient can lead to a multitude of errors including, but not limited to medication errors, incorrect diagnosis, patients undergoing unnecessary treatments and or procedures. There is also the risk of patient health information being wrongfully released from the healthcare facility. These types of errors stemming from incorrect patient identification can lead to significant legal and financial implications for any healthcare entity.


These errors does not stop just with the patient. Many times you will hear incorrect patient identification information exchanged between departments.


Remember, there are  only two data points  recognized as acceptable methods of identifying patients. These include verification of a  patient's name  and  date of birth . Once again, not only is this education critical for all new employees, but we cannot emphasize enough the importance of annual and ongoing training. 


In Summary


It is hard to believe that we still continue to miss the mark on what would seem to be some of the most simplistic tasks, but the fact is that we continue to do so. Adverse outcomes can be prevented and eliminated through development of comprehensive Infection Prevention and Quality Improvement Programs in addition to new and ongoing employee education. 

AED in a white cabinet on a green tiled wall, with a heart symbol and AED signage.
February 28, 2026
February may be the shortest month of the year, but in the world of healthcare facilities and regulatory oversight, it often feels like the longest. Between the launch of the Joint Commission’s Accreditation 360 and the sudden shifting of federal staffing mandates, your compliance "To-Do" list likely looks more like a "To-Don't-Panic" list. Below is your breakdown of the critical updates, deadlines, and strategic shifts defining February 2026. Regulatory Roundup: The "Great Repeal" of 2026 The most significant news hitting desks this month is the formal pivot in Long-Term Care (LTC) staffing. CMS Staffing Mandate Repealed : Effective February 2, 2026 , CMS officially rescinded the 2024 minimum staffing requirements (the 3.48 HPRD mandate). The Fine Print : While the "one-size-fits-all" numbers are gone, the Enhanced Facility Assessment requirements are still very much alive. Regulators are moving away from rigid ratios toward a "competency-based" model. You must still prove your staffing levels match your specific resident acuity. What it means for you : It’s time to double-check your assessment documentation. Auditors aren't counting heads as strictly, but they are scrutinizing the logic behind your staffing decisions. HIPAA & Privacy: The February 16th Pivot If you haven't updated your Notice of Privacy Practices (NPP) yet, you are officially behind. February 16, 2026, marked the deadline for compliance with the final rule aligning 42 CFR Part 2 (Substance Use Disorder records) with HIPAA. Lawful Holder Doctrine : Any practice receiving SUD records is now a "lawful holder," triggering new obligations for how those records are handled in legal proceedings. Reproductive Health Privacy : New prohibitions are in place regarding the disclosure of PHI for investigations into lawful reproductive healthcare. Security Rule Modernization : Th e HHS Office for Civil Rights (OCR) is phasing out the "addressable" vs. "required" distinction. By late 2026, every safeguard will be mandatory. Tech & Sustainability: Do Less with Less The 2026 facility mantra has shifted from "do more with less" to "do less with less"—meaning we are using data to eliminate wasted effort. Unified Platforms : The era of separate spreadsheets for maintenance, energy, and compliance is over. Integrated CAFM (Computer-Aided Facility Management) tools are now the standard for audit-ready reporting. The "Heart" of the Facility : Since it’s American Heart Month, it’s the perfect time to run a Life Safety check on AEDs and Cardiac Crash Carts. Ensure your battery replacement logs are digitized—paper tags are so 2024. A Note on Candor : Let’s be real—the repeal of the staffing mandate might feel like a relief, but it’s actually a trap for the unprepared. Without a fixed ratio to hide behind, your clinical judgment is the only thing standing between you and a "Statement of Deficiencies." Don't let the lack of a mandate lead to a lack of a plan.
Person holding a red heart and wooden blocks spelling
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