Infection Prevention and Control: Closing the Gaps in Ambulatory Care

Infection Prevention and Control (IPC) remains a foundation of patient safety in ambulatory surgery centers and other outpatient settings. Yet, findings from the 2024 AAAHC Quality Roadmap reveal that many organizations continue to face significant challenges in meeting IPC standards. These deficiencies not only pose risks to patient outcomes but also jeopardize accreditation status and regulatory compliance.

Let’s explore the most common IPC gaps and how healthcare leaders can address them proactively.

1. Inadequate Policies and Procedures

One of the most frequently cited issues is the lack of comprehensive, up-to-date infection control policies. Many organizations fail to align their protocols with current CDC and OSHA guidelines, leaving staff without clear direction. Policies should be approved by the governing body, reviewed annually, and updated whenever new evidence or regulations emerge.

2. Staff Training and Competency

Even the best policies are ineffective without proper implementation. AAAHC surveyors found that many facilities lacked documentation of staff training in infection control practices. Moreover, competency assessments were either missing or insufficient. Regular training sessions, followed by hands-on evaluations, are essential to ensure that all team members—from nurses to environmental services—understand and apply IPC principles correctly.

3. Environmental Cleaning and Disinfection

Cleanliness is non-negotiable in healthcare settings, yet inconsistent cleaning schedules and improper disinfectant use were common findings. Facilities must establish clear protocols for routine and terminal cleaning, including product selection and dry times. Auditing these practices regularly can help identify and correct lapses before they impact patient safety.

4. Sterilization and High-Level Disinfection

Sterilization errors can have serious consequences. AAAHC identified deficiencies such as incomplete sterilization logs, missing biological indicators, and failure to follow manufacturer instructions. Organizations should implement robust tracking systems and ensure that staff are trained in the nuances of reprocessing medical instruments.

5. Hand Hygiene Compliance

Despite being one of the simplest and most effective infection control measures, hand hygiene compliance remains a challenge. Facilities often lack monitoring systems or fail to enforce hand hygiene protocols. Ensuring the availability of hand sanitizers, conducting periodic audits, and fostering a culture of accountability can significantly improve compliance rates.

6. Personal Protective Equipment (PPE) Usage

Improper use of PPE—such as incorrect donning and doffing—was another common deficiency. PPE should be readily accessible, and staff must be trained in its correct use. Visual reminders and refresher courses can reinforce proper techniques and reduce the risk of contamination.

7. Infection Surveillance and Reporting

Finally, many organizations lacked formal systems for tracking and reporting infections. Surveillance is critical for identifying trends, responding to outbreaks, and meeting regulatory requirements. Facilities should establish clear reporting pathways and use data to drive continuous improvement.

Moving Forward

Addressing these deficiencies requires a coordinated effort across departments. By investing in education, standardizing procedures, and leveraging data, ambulatory care organizations can strengthen their infection control programs and enhance patient safety.

Take the Lead in Infection Prevention

Elevate your expertise and protect your patients by enrolling in AORN’s ASC Academy Infection Prevention Online course or tackle the CAIP^TM certification exam with confidence with the help of ASC Academy: Prep for Infection Prevention Certification course. These evidence-based programs are designed to help perioperative professionals master the latest standards, sharpen compliance strategies, and prepare confidently for certification.

Don't wait—empower your team and strengthen your infection control program today.

Become an Infection Prevention Expert

Secure your registration for one of AORN’s infection prevention courses mentioned above by Nov. 15, 2025, and get complimentary access to an Infection Preventionist Competency Verification Tool. Plus, the CAIP exam review course includes bonus access to eGuidelines Plus for six months to support your preparation. Get the offer details.