AAAHC Releases 2025 Quality Roadmap: Infection Prevention and Control Remains a Top Challenge

The Accreditation Association for Ambulatory Health Care (AAAHC) has released its 2025 Quality Roadmap, an annual report summarizing survey results from May 2024 through May 2025 across ambulatory surgery centers (ASCs), office-based surgery centers, primary care practices, and Medicare deemed status facilities. The findings are drawn directly from onsite accreditation surveys conducted under AAAHC's current standards (v43), which are set to be replaced on Dec. 16, 2025.

While most organizations achieve accreditation, the report underscores a familiar reality: infection prevention and control (IPC) remains one of the most challenging areas for compliance.

IPC in Surgical and Procedural Organizations

Nearly 90% of all surveys were conducted in ASCs and office-based surgery centers, where surveyors frequently cited IPC deficiencies. The three most common breakdowns were:

• unsafe sterilization and high-level disinfection practices (IPC.170, cited in 13.3% of facilities);

• inadequate program descriptions that failed to show how infections are prevented, identified, and managed (IPC.130, cited in 12.1%); and

• lack of a governing body-approved written IPC program (IPC.100, cited in 9.3% of facilities).

These findings point to both governance and frontline practice gaps. Policies may exist on paper, but they often lack the oversight and follow-through required to ensure staff are consistently protecting patients from infection risks.

IPC in Primary Care Organizations

In primary care settings, IPC was the single-most cited area of noncompliance. Surveyors most often noted:

• the absence of a formal, documented IPC program (IPC.100, cited in 15.2% of facilities);

• programs that lacked sufficient detail on surveillance and prevention practices (IPC.130, cited in 14.7%);

• and weaknesses in sterilization and disinfection processes (IPC.170, cited in 14.2%).

These results reflect a recurring challenge in outpatient clinics, where lean staffing and limited resources often leave infection control as an "add-on" responsibility rather than a fully supported program led by a qualified professional.

IPC and Immediate Jeopardy

According to the Quality Roadmap, infection control accounted for 22% of all immediate jeopardy (IJ) incidents over the past year. Many of these were tied to IPC.110 and IPC.170, where surveyors observed unsafe injection practices, failure to follow manufacturer instructions for cleaning scopes, reuse of disposable gowns, and cross-contamination caused by flawed workflows.

These lapses aren't minor. They represent immediate threats to patient safety and can jeopardize both accreditation and Medicare certification.

Why the Findings Matter: Infection Prevention and Control Standards in the Spotlight

Accreditation isn't just about passing a survey. It's about building systems that protect patients every day. IPC deficiencies persist because governing bodies often don't provide sufficient oversight, staff training isn't reinforced over time, and cultural gaps allow unsafe shortcuts. The 2025 Quality Roadmap makes clear that organizations must treat IPC not as a compliance checkbox but as a core component of safe, high-quality care.

IPC Compliance Readiness: Don't Risk Waiting

Infection prevention and control remains a key differentiator between organizations that excel during surveys and those that stumble — sometimes with serious consequences, including failed surveys, patient harm, and even the loss of insurance contracts or the ability to operate.

And with new AAAHC standards taking effect in December, the clock is already ticking. Organizations that wait until their next survey window to address IPC gaps may find themselves scrambling to catch up or worse, falling short when the stakes are highest.

If your last survey raised red flags in IPC, or if you're unsure whether your current program meets the latest expectations, now is the time to act.

Let's talk. Infection Control Consulting Services (ICCS) helps organizations get ahead of new standards, strengthen IPC policies and practices, and prepare staff to demonstrate compliance every day of the accreditation cycle. Don't wait until surveyors are at your door. Make sure your IPC program is airtight now.

What Does an Infection Control Consultant Do for Ambulatory Surgery Centers?

By Phenelle Segal, RN, CIC, FAPIC

Regulatory agencies and accrediting organizations place heavy emphasis on infection prevention and control in ambulatory surgery centers (ASCs). These bodies expect ASCs to treat patient safety, survey readiness, and compliance as constant priorities, and the margin for error is slim.

For many surgery centers, partnering with an experienced infection control consultant is the most effective and efficient way to stay on top of and meet infection control and prevention requirements, reduce risks, and create a safer environment for patients and staff alike.

Common ASC Infection Control Challenges

Despite ASCs operating differently than hospitals, their infection prevention requirements are no less rigorous. ASCs are expected to pay close attention to every step of the patient journey, from preop through surgery through discharge, to prevent healthcare-associated infections (HAIs). However, doing so can be difficult. Common infection control challenges facing today's ASCs include:

• Survey preparation and compliance: CMS, AAAHC, Joint Commission, QUAD A, ACHC, and state health departments all maintain strict infection control standards. Keeping up with the breadth of requirements and their ongoing challenges can be a full-time job in itself.

• Resource limitations: Given that most ASCs operate with lean staffing models, infection prevention and control responsibilities are often added to clinical or administrative roles. This can makes it difficult for those tasked with these responsibilities to devote the necessary time, focus, and expertise to ensuring their ASCs are meeting requirements and staying survey ready.

• Sterile processing: Proper cleaning, disinfection, and sterilization of surgical instruments is one of the highest-risk areas for ASC survey deficiencies.

• Antimicrobial stewardship: Prescribing and usage practices are increasingly scrutinized, requiring ASCs to establish programs that align with national standards.

• Written plans and risk assessments: Facilities must not only have comprehensive infection prevention plans in place, but they must also demonstrate that those plans are tailored to their unique environment and consistently followed and updated, when necessary.

When any of these areas fall short, ASCs face consequences ranging from costly citations to reputational damage. In some instances, shortcomings can even lead to operations being suspended.

How an Infection Control Consultant Supports ASCs

A certified infection control (CIC) consultant brings specialized expertise to help ASCs meet regulatory expectations and improve patient outcomes. At Infection Control Consulting Services (ICCS), for example, our team tailors solutions to the needs of each surgery center. Services typically delivered to our ASC clients include one or more of:

• Survey preparation: On-site assessments that identify potential deficiencies before a surveyor does, complete with actionable recommendations.

• Risk assessments: Facility-wide reviews of practices, policies, and environments to pinpoint vulnerabilities.

• Plan development and updates: Customized infection prevention and control programs, OSHA bloodborne pathogen and TB exposure control plans, and antimicrobial stewardship programs designed to meet ASC-specific requirements.

• Education and training: Targeted education and training sessions for staff at all levels, better ensuring infection prevention protocols are understood and consistently applied.

• Onboarding and mentoring: Guidance for new infection preventionists or staff tasked with ASC infection control responsibilities.

• Plan of correction support: Assistance with developing and implementing corrective action plans following survey deficiencies.

• Sterile processing guidance: Direct observation and feedback to ensure best practices are consistently maintained.

• Outbreak investigations: Expertise in root cause analysis and corrective measures for surgical site infections (SSIs) or other infection-related events.

Each of these services is designed not only to address compliance but also to foster a stronger culture of safety and accountability within the ASC.

Why Partner With ICCS

The ICCS team has over 40 years of experience in infection prevention and control, serving healthcare facilities, including ambulatory surgery centers, nationwide. Several members of our consulting team hold the FAPIC credential, a recognition awarded by the Association for Professionals in Infection Control and Epidemiology to leaders in the field.

Working with ICCS gives ASCs more than an individual consultant. It provides access to a team-based approach supported by peer collaboration, ongoing education, and a depth of experience across multiple ASC and other facility types. This means your surgery center benefits from proven strategies and insights refined over decades of practice.

The Value and ROI of Partnering With Infection Prevention Consultants

Engaging an ASC infection control consulting firm may feel like an added expense, but in reality, it is a cost-saving strategy. Consider the alternatives:

• A full-time infection preventionist may be cost-prohibitive, and turnover can disrupt continuity.

• A survey citation or regulatory fine can far exceed the investment in infection prevention consulting services.

• Outbreaks, SSIs, or lapses in sterile processing not only affect patient safety but can also damage the ASC’s reputation and financial viability.

By contrast, a consulting partnership offers flexibility and consistency. Whether through a one-time assessment, ongoing support, or hybrid arrangement, ASCs gain immediate access to seasoned professionals who strengthen compliance, reduce risk, and ultimately improve patient outcomes.

ASC Infection Control Is Too Important to Leave to Chance

Surgery centers exist to provide patients with safe, efficient surgical care outside of the hospital setting. To do that successfully, infection prevention cannot be a secondary responsibility. It must be treated as a priority. A partnership with an ASC infection control consulting firm like ICCS ensures your ASC has the people, expertise, and resources necessary to meet requirements and maintain ongoing compliance, protect patients and personnel, and instill confidence in both staff and surveyors.

Let ICCS Help Strengthen Your ASC’s Infection Prevention Program

ICCS has supported ambulatory surgery centers across the United States with infection prevention services tailored to their unique needs. From survey readiness to sterile processing guidance and antimicrobial stewardship, our consultants bring the expertise and stability today's ASCs require.

If your surgery center is looking to strengthen its infection control program, relieve the burden on staff, and better ensure short- and long-term compliance, ICCS is here to help. I invite you to contact us today for a complimentary consultation to discuss how our team can support your ASC’s infection prevention and control goals.

Why More Critical Access Hospitals Are Turning to Infection Control Consultants

By Phenelle Segal, RN, CIC, FAPIC

Critical access hospitals (CAHs) play an essential role in delivering healthcare to rural and underserved communities. With a focus on emergency care, shorter stays, and limited capacity, these facilities are often lifelines for patients who would otherwise have to travel hours for treatment. But operating with fewer resources doesn't mean fewer responsibilities, especially when it comes to infection prevention and control.

Over the last several years, Infection Control Consulting Services (ICCS) has worked with a growing number of critical access hospitals that are seeking outside support for their infection control programs. While many facilities initially assigned infection prevention responsibilities to staff nurses or quality managers, a pattern has emerged: infection control is too important, too regulated, and too demanding to be treated as an afterthought.

We thought it would be helpful to discuss some of the reasons why more CAHs are moving toward partnering with certified infection control (CIC) consultants, like those at ICCS, and why it is often the best solution for long-term compliance and patient safety.

Infection Control Regulations Are Complex and Ever-Changing

One of the biggest challenges CAHs face is keeping up with the web of regulations tied to infection prevention. These include federal rules from the Centers for Medicare & Medicaid Services (CMS), guidelines from The Joint Commission and other accreditation organizations, as well as state-specific laws and public health requirements. It's a lot to track, especially for smaller facilities with limited administrative bandwidth.

CIC consultants are trained specifically in this area. They not only stay current with the latest regulatory expectations but also understand how to translate those into practical, day-to-day workflows. Whether it's preparing for a survey, responding to audit findings, or developing policies aligned with national standards, consultants bring a level of expertise that is difficult to match internally, especially when infection control is only one of many hats a nurse might be wearing.

In the case of consultants who are also supported by an organization like ICCS, you gain the added benefit of a structured, team-based approach. These consultants have access to peer collaboration, ongoing training, and centralized resources that enhance both consistency and depth of expertise. This means your facility isn't just relying on one person's knowledge, but on a network of professionals dedicated to infection prevention and regulatory compliance, which brings scalable support when and where it's needed most.

Staff Nurses Are Already Overextended

In a typical CAH, nursing staff are the backbone of the operation. They're managing patient care, handling documentation, responding to emergencies, and often filling multiple roles at once. When infection prevention is layered on top of these responsibilities, it frequently takes a back seat. That happens not out of neglect, but out of necessity.

We've seen firsthand how well-intentioned staff struggle to give infection control the attention it requires. Surveillance, data tracking, root cause analysis, policy development, staff training — it's a full-time job, and then some. Infection prevention needs to be proactive, not reactive, and that can't happen when the person responsible is pulled in five different directions.

Consultants Offer Flexibility and Cost-Efficiency

Hiring a full-time infection preventionist can be a significant — and sometimes impossible — burden for smaller hospitals. There's the cost of recruitment, onboarding, salary, benefits, and training — not to mention the challenges of finding someone who is both qualified and willing to relocate to a rural area. And even if you succeed in hiring, there's always the risk of turnover or extended absence, which can leave the CAH without critical infection prevention support.

Contracting with an infection control consulting firm — particularly one with CAH experience and expertise — offers a cost-effective alternative. Rather than building a program from scratch or overextending internal resources, CAHs gain immediate access to experienced professionals who can hit the ground running. These consultants work on flexible schedules and can tailor services to the specific needs of the facility — whether that's a one-time assessment, ongoing monthly support, or a hybrid model.

Continuity of Support Makes a Measurable Difference

Turnover in infection prevention roles is a common issue across healthcare settings, and the disruption can be especially damaging in smaller hospitals. When a staff member leaves, institutional knowledge often goes with them, and the infection control program can lose momentum or even stall.

Consulting services offer stability. When ICCS partners with a facility, the assigned consultant typically remains with that CAH for the duration of the engagement. This consistency allows for the development of trust, familiarity with the facility's processes and culture, and a deeper understanding of ongoing challenges. Over time, that relationship becomes one of the most valuable assets in the hospital's infection prevention toolbox.

Strategic Insight Beyond Compliance

Infection control isn't just about passing surveys or avoiding citations. At its core, it's about protecting patients and staff from preventable harm. Experienced consultants bring more than regulatory knowledge. They bring strategy.

We often work with CAHs to improve areas like hand hygiene adherence, reduce surgical site infections (SSIs), strengthen antimicrobial stewardship programs, and develop meaningful quality improvement initiatives. Many of these facilities don't have dedicated teams to lead this work, but with a consultant's guidance, they're able to implement sustainable solutions that improve outcomes over time.

And because we're not embedded in the day-to-day, we can offer an outside perspective that's sometimes harder to come by when you're working from within. This objectivity can be a valuable tool for identifying blind spots, addressing systemic issues, and fostering an even stronger culture of safety.

Why It Matters Now More Than Ever

There's no arguing that the COVID-19 pandemic reshaped how the world views infection control. What used to be considered a behind-the-scenes function is now front and center, and under greater scrutiny than ever before. Healthcare-acquired infections (HAIs), antimicrobial resistance, compliance breakdowns, and staff burnout all carry real consequences. For CAHs already stretched thin, the risks are further amplified.

Bringing in a certified consultant isn't just about checking a regulatory box. It's about ensuring that infection prevention is strong, sustainable, and tailored to the unique demands of the facility. With limited staff and finite resources, every decision matters — and having expert support in your corner can make all the difference.

Let ICCS Help Strengthen Your Critical Access Hospital's Infection Prevention Program

ICCS has supported hospitals and healthcare facilities, including CAHs, across the country with infection prevention consulting services tailored to their needs. If your critical access hospital is looking to enhance its infection control program, ensure compliance, or simply relieve the burden on your internal staff, our experienced consultants are here to help. I invite you to contact ICCS so we can discuss how our team can support your infection control and prevention needs and goals.