By Phenelle Segal, RN, CIC, FAPIC, Founder, Infection Control Consulting Services
Key Takeaways
Update your infection control risk assessment and confirm this year's goals, and make sure annually renewed policies, including your exposure control and bloodborne pathogens plans, are current.
Validate technical competencies: Review your water management plan and Legionella risk assessment against ANSI/AAMI ST108, and confirm sterilization and high-level disinfection (HLD) competencies are documented.
Reconcile your NHSN surveillance data and reassess your antimicrobial stewardship program against current CMS and accreditation requirements.
Review hand hygiene compliance trends and schedule a mock survey or environmental rounds if you haven't had one this year.
Check your policies against new guidance issued this year, and start budget conversations now for next year's infection prevention and control support.
Every fall, I start hearing from facilities that want a mock survey done before the holidays or a risk assessment updated before their books close for the year. Whatever the end of the year looks like at your facility, a handful of infection prevention and control tasks are worth finishing before January rather than carrying into next year's survey cycle. None of these tasks are complicated on their own. They get difficult when several land in the same few weeks or months, on top of everything else your team is handling.
1. Update Your Infection Control Risk Assessment and Annual Goals
Your infection control risk assessment should reflect what happened this year. Too many facilities treat it as a formality and leave it matching whatever they wrote back in January. Look at the goals you set alongside it. If you met them, decide what comes next. If you didn't, figure out why before the same target carries forward unchanged. This is also the moment to flag anything new, such as a renovation, new equipment or a change in service lines, that should shape next year's risk priorities.
2. Confirm Annual Policy and Plan Renewals Are Current
Several plans carry an annual review requirement, and it's easy to let a review date slip when there's no dedicated compliance calendar tracking it. Lapses tend to show up in:
Bloodborne pathogen exposure control plan
TB exposure control plan and TB risk assessment
Facility-specific policies tied to your annual review cycle
Check your full policy list against requirements for your facility setting. A policy with an outdated review date is a deficiency waiting to happen during your next survey.
3. Review Your Water Management Plan Against ANSI/AAMI ST108
Water management plans and Legionella risk assessments (RA) need periodic review even in years when nothing obviously changed. Facilities that provide services requiring reprocessing of instruments and devices (e.g. surgical services) including outpatient surgery centers, acute care hospitals, critical access hospitals (CAHs), and micro-hospitals should confirm their plan reflects ANSI/AAMI ST108, the current standard from the Association for the Advancement of Medical Instrumentation (AAMI) governing water quality for device reprocessing. I still occasionally run into plans that cite guidance from AAMI TIR34:2014/(R)2021, which ST108 has since replaced, sometimes years after the update.
4. Validate Sterilization and High-Level Disinfection Competencies
Sterile processing staff need periodic competency validation, and it's one of the more commonly cited findings I see across central sterile processing departments regardless of facility type. Before the year ends, confirm every staff member with reprocessing responsibilities has current, documented competency validation performed by a professional with training in reprocessing. Initial training from years ago doesn't carry forward on its own.
5. Reconcile Your NHSN Surveillance Data
If your facility reports to the National Healthcare Safety Network, or NHSN, year-end is when I tell clients to reconcile their data rather than wait for a submission deadline to surface a problem.
6. Reassess Your Antimicrobial Stewardship Program
Antimicrobial stewardship is a CMS requirement for acute care hospitals, CAHs, and long-term care facilities (LTCFs), and accreditation organizations tend to maintain their own related standard. Programs should be reassessed against current requirements every year. Even a program that was designed correctly at launch can move out of alignment and compliance as guidance changes. If your antimicrobial stewardship program hasn't been reassessed in a while, now is a good time to check that box.
7. Pull Your Hand Hygiene Compliance Data
Hand hygiene data gets collected at most facilities I work with. Reviewing it closely enough to catch a pattern happens less often. Before the year closes, pull your trends and look for a pattern, such as a unit that consistently underperforms or a shift with noticeably lower numbers than the rest. That pattern gives you something concrete to act on heading into next year, which is much more useful than a single overall percentage. Hand hygiene remains the foundation of Standard Precautions, so any concerning trend is worth following up on and acting on.
8. Schedule a Mock Survey or Environmental Rounds
If your facility hasn't had a mock survey or a full round of environmental observations this year, don't let it slip into next year unscheduled. I run these visits specifically to catch what staff walk past every day without noticing. A mock survey gives you that outside perspective while there's still time to act on it.
9. Check for New CDC, CMS, or Accreditation Agency Guidance
CDC, CMS, and accreditation agencies may issue updates throughout the year, and I've seen facilities miss one simply because nobody was assigned to track it. Set aside time before the end of the year to compare your policies against what changed this year, rather than assuming everything is still current.
10. Start Budgeting for Next Year's Infection Control Support
If outside support is going to be part of next year's plan, start that conversation early. Waiting until the need is urgent narrows your options. A few things possibly worth budgeting for:
Survey preparation, if one is anticipated in the next six months to a year
Additional staffing or outside support where your team needs the coverage; this may include fractional support if your organization would benefit from ongoing expert oversight
Program-specific initiatives planned for next year, like a major risk assessment or onboarding and mentoring of new infection prevention staff
Budget cycles move slower than project timelines, and facilities that wait until they need help are often waiting longer than they'd like.
Final Thoughts
These 10 tasks can be straightforward individually. They get hard to manage when facilities wait until the final few weeks of the year to tackle all of them at once, after everything else on the calendar is already set. Starting now gives you room to get through the list without rushing. If it turns up more work than your team can handle internally before year-end, contact ICCS and my team will help you sort out what should happen, when, and where we can help.
Frequently Asked Questions About Year-End Infection Control Tasks
What is the most important task to finish before year-end?
If you only get through one, consider making it the infection control risk assessment, sometimes called an ICRA and distinct from the construction-specific risk assessment of the same name, and goals review. Everything else on this list can be easier to prioritize once you know where your program stands and what changed over the past year.
How far in advance should we start budget conversations for next year's infection control needs?
Start well before year-end if possible. Budget approvals and vendor scheduling both take longer than most facilities expect, and firms that get requests earlier in the fall have more flexibility than those calling in January, when demand picks up.
Is a mock survey necessary every year?
It depends on your accreditation agency’s survey cycle and how confident you are in your program's current state. I recommend a mock survey now for any facility due for survey in the next 6 to 12 months, but even facilities with more runway tend to find value in a fresh set of eyes at least once a year.
What happens if a facility doesn't get through this list before January?
Nothing happens automatically, but the tasks don't disappear. They just get harder to prioritize once new items start competing for attention in the new year. I'd rather see a facility work through even a few of these before year-end than start January from zero.
Do these tasks apply to every type of facility?
Most of them apply broadly, though a few carry facility-specific nuances. It's worth checking a given requirement against your specific facility type and accreditation agency, since requirements can differ meaningfully between, for example, an ambulatory surgery center and a critical access hospital.