Report to Congressional Requesters

United States Government Accountability Office

GAO 

HEALTH-CAREASSOCIATED 

INFECTIONS 

HHS Action Needed to 

Obtain Nationally 

Representative Data 

on Risks in 

Ambulatory Surgical 

Centers 

February 2009 

GAO-09-213 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

February 2009

HEALTH-CARE-ASSOCIATED INFECTIONS

HHS Action Needed to Obtain Nationally 

Representative Data on Risks in Ambulatory Surgical 

Highlights of GAO-09-213, a report to Centers

congressional requesters 

Health-care-associated infections 

(HAI) are a leading cause of death. 

Recent high-profile cases of HAIs 

in ambulatory surgical centers 

(ASC) due to lapses in 

recommended infection control 

practices may indicate a more 

widespread problem in ASCs, but 

the prevalence of such lapses is 

unknown. 

The Department of Health and 

Human Services’ (HHS) Centers for 

Medicare & Medicaid Services 

(CMS) and other entities collect 

data on HAIs, including process 

data on the use of recommended 

practices and outcome data on HAI 

incidence. CMS conducts standard 

surveys on about half of ASCs 

every 3 to 4 years, assessing 

compliance with its standard on 

infection control. In this report, 

GAO examines the availability of 

data on HAIs in ASCs nationwide. 

GAO interviewed subject-matter 

experts, agency officials, and trade 

and professional group officials. 

What GAO Recommends

To collect nationally representative 

and standardized information on 

ASC compliance with infection 

control practices that reduce HAIs, 

GAO recommends that the Acting 

Secretary of HHS develop and 

implement a written plan to use the 

data collection instrument and 

methodology tested in the ASC 

pilot to conduct recurring periodic 

surveys of randomly selected ASCs. 

In response, CMS concurred with 

the recommendation. 

Disparate sources of data on HAIs in ASCs are available, but none provide 

information on the extent of the problem nationwide. Such data are useful for 

guiding federal policies aimed at preventing the lapses in infection control 

practices—such as reusing syringes and drawing medication to be injected 

into multiple patients from single-dose vials—that can lead to increased risk 

of HAIs for patients. GAO identified five data sources—two operated by HHS, 

two by professional organizations, and one by a state government—all of 

which differ from one another in the type of HAI information they collect. 

In order to make nationwide estimates of HAIs and lapses in related infection 

control practices in ASCs, a data source would need to collect its data from a 

nationally representative random sample of ASCs. However, none of the five 

sources does so. The two professional organizations and the state source 

collect data from narrowly defined subsets of ASCs. The most detailed data 

are provided by the two federal sources, one of which collects outcome data 

and the other process data. Experts GAO interviewed said it was more 

feasible for ASCs to collect process data than outcome data. The Centers for 

Disease Control and Prevention’s (CDC) National Healthcare Safety Network 

collects detailed, standardized data on HAI outcomes that are comparable 

across hospitals and other health care facilities, but it has only recently begun 

to collect data on ASCs and it is not set up to collect nationally representative 

data. The other HHS data source, a CMS ASC pilot study conducted in three 

states, collects detailed process data on practices that affect the risk of HAIs. 

The pilot study tested the application of two innovations—a CDC-developed 

infection control assessment tool and direct observation by the surveyor of a 

single patient’s care from start to finish of the patient’s stay—during the 

course of CMS’s standard surveys of selected ASCs. These innovations 

allowed surveyors to identify serious lapses in CDC-recommended infection 

control practices that would not have been detected during CMS’s standard 

surveys of selected ASCs. A CMS official told GAO that CMS officials would 

consider making changes to CMS’s standard survey process after reviewing 

planned CMS and CDC analyses of the pilot study results but did not expect to 

collect standardized quantitative data on the extent of compliance with 

specific infection control practices using a data collection instrument, as was 

done with the assessment tool for the pilot. Even if CMS were to continue the 

pilot’s data collection methods, the data would not be generalizable to ASCs 

nationwide—and thus could not provide information on the extent of the 

lapses—because ASCs are selected for surveys on the basis of their perceived 

risk for quality issues and the length of time since they were last surveyed, 

rather than through random selection. A random sample—the size of which 

CMS could determine—could generate national estimates that would identify 

those infection control practices where lapses by ASCs across the country 

were most likely to put their patients at risk of contracting HAIs. To view the full product, including the scope 

and methodology, click on GAO-09-213. 

For more information, contact Cynthia A. 

Bascetta at (202) 512-7114 or 

bascettac@gao.gov. 
Contents 

Letter 1

Results in Brief 4

Background 6 

Disparate Sources of Data on HAIs in ASCs Are Available, but 

None Provide Information on the Problem Nationwide 7 

Collecting Process Data on HAIs in ASCs Is More Feasible Than 

Collecting Data on Outcomes 16 

Conclusions 17 

Recommendation for Executive Action 19 

Agency Comments 19 

Appendix I Comments from the Centers for Medicare & 

Medicaid Services 22 

Appendix II GAO Contact and Staff Acknowledgments 25 

Table 

Table 1: Sources of Data on HAIs from ASCs 8 

Page i GAO-09-213 Infections in Ambulatory Surgical Centers 
Abbreviations 

AAAASF American Association for Accreditation of 

 Ambulatory Surgery Facilities, Inc. 

ASC ambulatory surgical center 

CDC Centers for Disease Control and Prevention 

CMS Centers for Medicare & Medicaid Services 

HAI health-care-associated infection 

HHS Department of Health and Human Services 

NHSN National Healthcare Safety Network 

SSI surgical site infection 

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Page ii GAO-09-213 Infections in Ambulatory Surgical Centers 
United States Government Accountability Office

Washington, DC 20548 

 

February 25, 2009 

Congressional Requesters 

Health-care-associated infections (HAI) are 1 of the top 10 leading causes 

of death in the United States, according to the Department of Health and 

Human Services’ (HHS) Centers for Disease Control and Prevention 

(CDC), and can cause needless suffering and expense. HAIs are infections 

that patients may acquire in a health care setting while receiving treatment 

for other conditions.1

 One such setting is ambulatory surgical centers 

(ASC), which are freestanding outpatient facilities where surgical 

procedures such as endoscopies and orthopedic or plastic surgery are 

performed.2

 Both the number of ASCs and the number of surgeries 

performed in ASCs have increased substantially since 1990. Currently, 

there are over 5,100 ASCs nationwide that provide services to Medicare 

beneficiaries. In 2007, more than 6 million surgeries were performed in 

ASCs and paid for by Medicare.3

Because patients in ASCs tended to be healthier than those in hospitals 

and the procedures performed in ASCs were less invasive and less 

complex, experts in infection control traditionally have considered the 

risk of infection in outpatient settings such as ASCs to be low.4

 However, 

in recent high-profile cases of HAIs in ASCs, large numbers of patients 

were put at risk and recommended to be tested for health-care-associated 

HIV and hepatitis infections. In one such case, approximately 40,000 

 

1

In general, HAIs are distinct from community-acquired infections, that is, infections 

acquired before entering the health care setting. The term health-care-associated infection 

is often used synonymously with the terms hospital-acquired infection and nosocomial 

infection. 

2

In this report, we are concerned exclusively with freestanding ASCs that participate in 

Medicare. These ASCs do not include hospital outpatient departments or physicians’ 

offices where surgeries are performed. Some freestanding ASCs may be affiliated with a 

hospital, however. 

3

Medicare is a federal health insurance program that serves over 42 million elderly and 

disabled beneficiaries and pays for certain health care services. Approximately 85 percent 

of all ASCs in the United States are approved to provide services to Medicare beneficiaries. 

While there are other ASCs that do not treat Medicare beneficiaries, in this report we focus 

on those approximately 5,100 ASCs that serve Medicare beneficiaries. 

4

C. Friedman et al., “Requirements for Infrastructure and Essential Activities of Infection 

Control and Epidemiology in Out-of-Hospital Settings: A Consensus Panel Report,” 

American Journal of Infection Control (27:418-30), 1999. 

Page 1 GAO-09-213 Infections in Ambulatory Surgical Centers 
 

patients in Nevada were potentially exposed to hepatitis C and other 

infectious diseases over a 4-year period because of lapses in adherence to 

basic infection control practices. These lapses included reusing syringes 

and drawing medication to be injected into multiple patients from singledose vials. Subsequent inspections of other ASCs in the state found similar 

problems, suggesting that such lapses are not isolated events but indicate 

a larger, more widespread problem. However, the prevalence of such 

unsafe practices is unknown. 

Two federal agencies have established standards and conducted other 

activities aimed at controlling and preventing HAIs in health care settings, 

including ASCs. CDC has issued evidence-based guidelines containing 

recommended practices, such as proper hand hygiene, to prevent HAIs. 

HHS’s Centers for Medicare & Medicaid Services (CMS) has developed 

health and safety standards5

 with which ASCs must comply in order to be 

certified as suppliers of Medicare-covered services. One of the health and 

safety standards covers infection control and requires each ASC to 

establish an infection control program for identifying and preventing 

infections and maintaining a sanitary environment.6

 CMS oversight of 

certified ASCs includes a provision for conducting on-site standard 

surveys of facilities to assess their compliance with the standards.7

 State 

survey agencies select ASCs for these surveys based on policies set by 

CMS. About half of ASCs are surveyed every 3 to 4 years. 

 

5

CMS calls these ASC standards “conditions for coverage.” 

6

In response to the dramatic growth since 1990 in the number of ASCs participating in 

Medicare and in the volume of procedures that they perform, CMS issued a revised set of 

standards for ASCs in November 2008. See 73 Fed. Reg. 68502, 68719-20, 68813 (Nov. 18, 

2008) (Adding 42 C.F.R. § 416.51). In addition to requiring ASCs to maintain a sanitary 

environment and an infection control program, the infection control standard requires 

ASCs to document that they have considered nationally recognized infection control 

guidelines and implemented those they have determined to be most relevant to their own 

operations. It also requires that the infection control program be directed by a designated 

and qualified professional with training in infection control. Discussion in this rule states 

that ASC clinical staff such as nurses and pharmacists could fill this role without additional 

training specific to infection control, as long as they received approximately 4 hours of 

continuing education in infection control each year. This rule is effective May 18, 2009. 

7

There are several types of CMS surveys, including standard and validation surveys, initial 

certification, complaint investigations, and revisits. In this report, we discuss only standard 

surveys. 

Page 2 GAO-09-213 Infections in Ambulatory Surgical Centers 
 

Other activities in HHS aimed at addressing the problem of HAIs include 

maintaining several databases in different HHS agencies, such as the 

database of CDC’s National Healthcare Safety Network (NHSN) program. 

In response to demands for more public information on HAIs, at least 23 

states have begun to develop and implement HAI public reporting 

systems—with 17 using CDC’s NHSN—to collect and disseminate HAI 

data from hospitals.8

 In addition, some states plan to include HAI data 

from ASCs in these reporting systems, with Missouri beginning to collect 

data in 2006. These data sources collect information related to HAIs, 

including process and outcome measures. Process measures record the 

use of procedures or practices, such as hand hygiene and safe injection 

practices, designed to reduce the incidence of infections. Outcome 

measures record actual incidence of an active infection such as a surgical 

site infection (SSI), or the transmission of an infectious agent such as 

hepatitis following a procedure. 

Previously, we reported that the extent of the HAI problem, while 

significant, was unknown because the data that CDC and other HHS 

agencies collect on HAIs in hospitals are limited in scope and lack 

integration across multiple databases.9

 We also found that resource and 

technological challenges have affected the implementation of states’ HAI 

public reporting systems.10 Data on the extent of the problem of HAIs 

nationwide are useful for guiding federal actions and policies aimed at 

preventing the lapses in infection control practices that can lead to 

increased risk of infection for patients in medical facilities. Given your 

continuing concern regarding HAIs and recent incidents involving HAIs in 

ASCs, in this report we (1) examine the extent to which data are available 

to understand the problem of HAIs in ASCs nationwide and (2) compare 

the feasibility of collecting outcome versus process data on HAIs in ASCs. 

To examine the extent to which data are available to understand the 

problem of HAIs in ASCs nationwide, we interviewed subject-matter 

experts and agency and organization officials knowledgeable about this 

 

8

GAO, Health-Care-Associated Infections in Hospitals: An Overview of State Reporting 

Programs and Individual Hospital Initiatives to Reduce Certain Infections, GAO-08-808 

(Washington, D.C.: Sept. 5, 2008), 2, 20. 

9

GAO, Health-Care-Associated Infections in Hospitals: Leadership Needed from HHS to 

Prioritize Prevention Practices and Improve Data on These Infections, GAO-08-283 

(Washington, D.C.: Mar. 31, 2008). 

10GAO-08-808, 24. 

Page 3 GAO-09-213 Infections in Ambulatory Surgical Centers 
 

topic. We identified six subject-matter experts by conducting a literature 

search to systematically find individuals who have published studies 

related to HAIs in ASCs. We interviewed the six subject-matter experts 

using a standard set of interview questions and received responses from 

all six. We also interviewed officials from the three main accrediting 

organizations;11 the ASC trade association; CDC and CMS; three 

professional organizations and one advocacy organization identified as 

having knowledge related to our research objectives;12 and three state 

survey agencies that were identified by CMS officials as participating in a 

pilot project involving infection control in ASCs.13 To compare the 

feasibility of collecting outcome versus process data on HAIs in ASCs, we 

asked all experts and CMS and CDC officials we interviewed to identify 

the challenges in collecting such data and how these challenges can be 

addressed. We conducted this performance audit from June 2008 through 

December 2008, in accordance with generally accepted government 

auditing standards. Those standards require that we plan and perform the 

audit to obtain sufficient, appropriate evidence to provide a reasonable 

basis for our findings and conclusions based on our audit objectives. We 

believe that the evidence obtained provides a reasonable basis for our 

findings and conclusions based on our audit objectives. 

Disparate sources of data on HAIs in ASCs are available, but none provide 

information on the extent of the problem nationwide. We identified five 

sources of data on HAIs in ASCs—two administered by HHS, two by 

professional organizations, and one by a state government—all of which 

differ from one another in the type of HAI information that they collect. In 

order to make nationwide estimates of HAIs and lapses in related infection 

control practices in ASCs that could be used in developing federal actions 

and policies designed to prevent these infections, a data source would 

need to collect its data from a nationally representative random sample of 

ASCs. However, none of the five sources does so. The two professional 

organizations and the state source collect data only from member ASCs or 

Results in Brief 

 

11These three accrediting organizations are the American Association for Accreditation of 

Ambulatory Surgery Facilities, Inc., the Accreditation Association for Ambulatory Health 

Care, and The Joint Commission. 

12These four organizations are the American Association of Nurse Anesthetists, the 

American Society for Gastrointestinal Endoscopy, HONOReform, and the Association for 

Professionals in Infection Control and Epidemiology, Inc. 

13These are the Maryland, North Carolina, and Oklahoma state survey agencies. 

Page 4 GAO-09-213 Infections in Ambulatory Surgical Centers 
 

from ASCs within a certain geographical area, respectively. The most 

detailed data are provided by the two federal sources. CDC’s NHSN—the 

most widely recognized source of data on HAIs—collects detailed, 

standardized data on HAI outcomes that are comparable across facilities, 

but it has only recently begun to collect data on ASCs and it is not set up 

to collect nationally representative data. The other HHS data source, a 

CMS ASC pilot study conducted in three states, collected detailed process 

data on practices that affect the risk of HAIs in ASCs. The pilot study 

tested the application of two innovations—a CDC-developed infection 

control assessment tool and direct observation by the surveyor of a single 

patient’s care from start to finish of the patient’s stay. These innovations 

allowed surveyors to identify serious lapses in CDC-recommended 

infection control practices. These lapses would not have been detected 

during the course of CMS’s standard surveys of selected ASCs. CMS 

officials told us that they intended to consider making changes to CMS’s 

standard survey process after reviewing planned CMS and CDC analyses 

of the pilot study results but did not expect to collect standardized 

quantitative data on the extent of compliance with specific infection 

control practices using a data collection instrument, as was done with the 

assessment tool for the pilot. Even if CMS were to continue the pilot 

study’s data collection methods, those data would represent only the ASCs 

actually surveyed under CMS’s current selection policies. The data would 

not be generalizable to ASCs nationwide—and thus could not provide 

information on the extent of the problem—because ASCs are selected for 

surveys on the basis of their perceived risk for quality issues and the 

length of time since they were last surveyed, rather than through random 

selection. A random sample—the size of which HHS could determine—

could generate meaningful national estimates to help identify where lapses 

in infection control practices by ASCs across the country were most likely 

to be putting patients at risk of contracting HAIs. 

Experts we interviewed stated that it was more feasible for ASCs to collect 

process data than outcome data. They noted that collecting outcome data 

in ASCs was challenging because patients were typically in ASCs for a 

relatively short period of time and would be more likely to seek follow-up 

care at a physician’s office or hospital emergency room than to return to 

the ASC. Therefore the ASC might never know that an HAI occurred, and 

so would be unable to report it. Several experts said that it was more 

feasible to collect process data to detect unsafe practices that might lead 

to HAIs than to track outcomes such as the transmission of HAIs to 

individual patients. They added that process data might also be more 

useful by pointing out areas for specific remedial training. 

Page 5 GAO-09-213 Infections in Ambulatory Surgical Centers 
 

To obtain nationally representative and standardized information on the 

extent to which ASCs implement specific infection control practices that 

reduce the risk of transmitting HAIs to their patients, we recommend that 

the Acting Secretary of HHS develop and implement a written plan to use 

the data collection instrument and methodology tested in the ASC pilot 

study, with appropriate modifications based on the CDC and CMS analyses 

of that study, to conduct recurring periodic surveys of randomly selected 

ASCs. 

We provided a draft of this report to HHS for comment. In written 

comments submitted by CMS, the agency concurred with our 

recommendation. CMS stated that it would use the results from the pilot 

study to determine whether it should incorporate the infection control 

assessment tool into the standard ASC survey process. The agency stated 

that if it decided to use the tool, then it would examine the potential to 

draw on CDC to provide training on the use of the tool and data analysis of 

the completed tools on an ongoing basis. Given such support, CMS stated 

its willingness to begin random selection of at least some ASCs in each 

state for ASC surveys. 

An ASC patient may acquire an HAI from bacteria or viruses 

contaminating, for example, the hands of a health care worker or a needle 

or tube used to deliver medicine, fluids, or blood. These bacteria or viruses 

may include those responsible for such illnesses as staphylococcus 

infections and hepatitis. 

Background 

Two agencies in HHS have activities under way to prevent, control, or 

monitor HAIs. CDC—a key HHS agency for research and programs 

designed to prevent HAIs—has issued 13 guidelines relevant to infection 

control and prevention in health care settings. In these guidelines, which 

are based on scientific evidence, CDC recommends practices for 

implementation to prevent HAIs.14 Practices recommended to prevent or 

control HAIs include, for example, appropriate isolation of infected 

patients in health care facilities, proper sterilization of equipment, 

appropriate provision of antibiotics to patients before surgery, annual 

vaccination of health care personnel for influenza, and hand washing or 

the use of alcohol-based hand rubs. 

 

14GAO-08-283, 12. 

Page 6 GAO-09-213 Infections in Ambulatory Surgical Centers 
 

CMS is responsible for ensuring that ASCs that are certified as suppliers of 

Medicare-covered services comply with its requirements for infection 

control. For most ASCs, this occurs through the state-administered 

standard survey process conducted by state survey agencies under 

contract with CMS. ASCs may choose instead to undergo accreditation by 

a CMS-approved accrediting organization.15 CMS-approved accreditation 

programs for ASCs have standards that meet or exceed Medicare’s 

standards. Accrediting organizations are to conduct periodic surveys of 

ASCs to assess their compliance with the standards established by the 

accrediting organization, including those related to infection control. The 

state survey agency or accrediting organization assesses compliance 

through direct observation of activities in the facility and review of its 

policy documents. If an ASC opts for the CMS state-administered survey 

process, a state surveyor uses CMS’s survey guidance to conduct the 

state’s compliance review of the ASC. 

We identified five disparate sources of HAI data, all of which differed from 

one another in the types of HAI information they collected. However, none 

obtained its data from a nationally representative random sample of ASCs, 

and therefore none could be used to develop national estimates of HAI 

outcomes or compliance with infection control practices that affect the 

risk of acquiring HAIs in ASCs. Two federal data sources—CDC’s NHSN 

and CMS’s ASC pilot study—provided the most detailed information on 

HAI outcomes and infection control practices, respectively. 

We identified five disparate data sources that currently collect data on 

HAIs in ASCs. HHS operates two of these data sources—CDC’s NHSN and 

CMS’s ASC pilot study. Two are maintained by professional associations—

the Ambulatory Surgery Center Association’s Outcomes Monitoring 

Project and the American Association for Accreditation of Ambulatory 

Surgical Facilities, Inc. (AAAASF) Internet-based Quality Assurance and 

Peer Review Reporting System. Finally, the state of Missouri collects data 

on HAIs in ASCs through its Missouri State HAI Reporting System. (See 

table 1.) 

Disparate Sources of 

Data on HAIs in ASCs 

Are Available, but 

None Provide 

Information on the 

Problem Nationwide 

Five Sources of Data for 

Separate, Non-NationallyRepresentative Patient 

Populations Provide 

Different Types of 

Information on HAIs in 

ASCs 

 

15The three primary accrediting organizations for ASCs are the American Association for 

Accreditation of Ambulatory Surgical Facilities, Inc., the Accreditation Association for 

Ambulatory Health Care, and the Joint Commission. The American Osteopathic 

Association also accredits a small number of ASCs. 

Page 7 GAO-09-213 Infections in Ambulatory Surgical Centers 
 

Table 1: Sources of Data on HAIs from ASCs 

Data sources 

Number of 

ASCs; time 

period 

Patient 

population 

Data collection 

method 

Outcomes 

recorded 

Process/practices 

recorded Data analysis 

CDC National 

Healthcare 

Safety Network 

(NHSN) 

Unknown; data 

from 2006 to 

present 

Patients 

undergoing 

selected 

procedures in 

enrolled facilities, 

some of which 

may be ASCs;a

some facilities 

enroll in NHSN 

voluntarily and 

others are 

required to do so 

under state law 

HAIs are detected 

by facility staff 

through prospective 

and post-discharge 

surveillance, which 

may include patient 

examination, 

medical record 

review, and/or 

communication with 

a patient or 

physicianb

Procedurespecific SSIsb

 

Central line 

insertion practicesc

Rates of SSIs, 

controlling for 

procedure type 

and patient risk 

factors 

CMS ASC Pilot 

Study 

Approx. 68;d 

data from 

June through 

October 2008 

Patients in ASCs 

certified for 

Medicare 

participation in 

Maryland, 

North Carolina, 

and Oklahoma 

Surveyors use a 

CDC-developed 

instrument to 

collect data during 

on-site inspections 

through interviews, 

document 

inspection, and 

observation 

None Training policies; 

procedures used to 

detect infections; 

practices for hand 

hygiene, injection, 

sterilization, and 

environmental 

cleaning 

Facility 

compliance with 

specified infection 

control practices 

Ambulatory 

Surgery Center 

Association 

Outcomes 

Monitoring 

Project 

Approx. 650; 

data from the 

mid-1990s to 

present 

Patients treated 

in ASCs that are 

members of the 

Ambulatory 

Surgery Center 

Association and 

choose to submit 

data 

ASCs report 

quarterly the total 

number of patients 

who match 

specified 

descriptions, such 

as experiencing 

wound infections or 

receiving antibiotics 

prior to surgery 

Aggregate 

number of 

post-procedure 

wound 

infections per 

quarter 

Aggregate number 

of patients for 

whom antibiotics 

were ordered and 

who received them 

within specified 

time frames prior to 

surgery to prevent 

infection 

Performance 

benchmarking 

compared to other 

ASCs 

American 

Association for 

Accreditation 

of Ambulatory 

Surgery 

Facilities, Inc. 

(AAAASF) 

Internet-based 

Quality 

Assurance and 

Peer Review 

Reporting 

System 

105 multispecialty or 

Medicarecertified ASCs;e

data from 2001 

to present 

Patients treated 

in facilities 

accredited by 

AAAASFf

Facilities are 

obligated to report 

all infections;g

 a 

physician peer 

reviews each of 

these cases and 

extracts from the 

patient’s medical 

record key 

information, such 

as type of infection, 

management, and 

outcome 

Aggregate 

number and 

rateh

 of 

infections plus 

eventual 

resolution of 

infection 

Antibiotics 

administered, 

wound 

management, 

length of stay if 

hospitalized 

Overall rate of 

infections and 

modes of 

treatment 

Page 8 GAO-09-213 Infections in Ambulatory Surgical Centers 
 

Data sources 

Number of 

ASCs; time 

period 

Patient 

population 

Data collection 

method 

Outcomes 

recorded 

Process/practices 

recorded Data analysis 

Missouri State 

HAI Reporting 

System 

26 in 2006; 

data from 2006 

to present 

Patients 

undergoing 

hernia or breast 

surgery in 

Missouri ASCs 

that performed at 

least 20 of those 

procedures 

during the 

previous 

calendar year 

HAIs are detected 

by facility staff 

during 30-day 

follow up, which 

may include patient 

exam, medical 

record review, or 

patient or physician 

surveyb

Procedurespecific SSIsbNone Rates of SSIs, 

controlling for 

procedure type 

and patient risk 

factors 

Sources: Interviews, documents, and contacts with agency and organization officials. 

a

Until recently, enrollment in NHSN had been limited to hospitals and outpatient hemodialysis centers. 

CDC officials nonetheless stated that they believed some ASCs had enrolled and entered HAI data 

into NHSN but they could not determine how many. NHSN includes, under the ASC category, 

surgical units within a hospital outpatient department. CDC has initiated a new survey of facilities 

enrolled in NHSN that will identify which are ASCs and distinguish between those located within 

hospitals and those that are freestanding. By February 2009, all enrolled facilities should have 

completed this survey. 

b

Database uses standard CDC definitions. 

c

Although central lines, which are intravenous lines inserted into a large vein typically in the neck or 

near the heart, are commonly used in hospitals, particularly in intensive care units, they can also be 

used in ASCs. 

d

Maryland agreed to survey 32 ASCs, North Carolina 16, and Oklahoma 20. The ASCs surveyed 

were randomly selected by CMS. 

e

These numbers do not reflect the total number of facilities in the AAAASF database, which includes 

both ASC and office-based surgery facility data. The majority of AAAASF’s accredited facilities are 

office-based surgical facilities that do not fall under Medicare’s ASC classification. 

f

In 1992 the American Association for Accreditation of Ambulatory Plastic Surgery Facilities expanded 

the scope of its accrediting activities to include facilities operated by physicians from other specialties 

and became the AAAASF. However, facilities performing plastic surgery remain a majority of the 

approximately 1,200 facilities accredited by AAAASF. 

g

Infections are one of the unanticipated sequelae that facilities participating in this system are 

obligated to report. 

h

These data are collected only on patients with identified infections. Overall infection rates are 

calculated by dividing the aggregate number of identified infections by the total number of procedures 

performed. 

Page 9 GAO-09-213 Infections in Ambulatory Surgical Centers 
 

The five data sources do not provide nationally representative information 

on HAIs in ASCs. In order to provide a basis for a nationwide estimate of 

risks of HAIs in ASCs, a data source would need to collect its data from a 

nationally representative random sample. None of the five data sources 

does so, and therefore it is not possible to generalize from their results to 

the nationwide population of ASCs or patients that they treat. 

Consequently, each of these data sources provides information only about 

the facilities that actually submit data to it and cannot reliably be used to 

describe other facilities.16

In terms of their coverage across ASCs, each of these data sources collects 

information on HAIs from a relatively small proportion of the 5,100 ASCs 

in the United States. The coverage ranges from the 26 ASCs that most 

recently reported data to the state of Missouri to about 650 ASCs reporting 

to the Ambulatory Surgery Center Association’s database. Moreover, 

which ASCs are included in each of the databases is determined by highly 

variable criteria.17 They include, depending on the database, a decision by 

the individual ASC to voluntarily participate, membership of the ASC in a 

particular professional association, and selection of an ASC based on its 

geographic location in a particular state. For example, all the ASCs in the 

ASC pilot study are from Maryland, North Carolina, or Oklahoma because 

those states volunteered to participate in the study, and the ASCs covered 

by the two professional organizations and the state source are taken from 

narrowly defined subsets of ASCs, that is, from member ASCs or from 

ASCs within a certain geographical area, respectively. 

The five data sources also vary in the type and level of detail of the 

information they collect. NHSN, AAAASF, and Missouri’s system collect 

data on individual patients, and the ASC pilot study and the Ambulatory 

Surgery Center Association’s database collect data that are aggregated to 

the facility level. Four of the five data sources—all but the ASC pilot 

study—collect information on patient outcomes, specifically rates of SSIs. 

However, of those four, only the federal NHSN and state of Missouri 

databases employ standard CDC definitions to identify cases with SSIs 

 

16An exception applies to the three states that participated in the ASC pilot. CMS officials 

reported that the ASCs surveyed as part of the pilot were randomly selected by CMS in 

each of the three states. In principle, this would make the findings from these surveys 

generalizable to the ASCs in each of these states, but not to ASCs in any other state. 

17It is possible that some ASCs are included in more than one data source. 

Page 10 GAO-09-213 Infections in Ambulatory Surgical Centers 
 

based on these criteria.18 The two professional association databases leave 

identification of SSIs to individual physician judgment. Both professional 

association databases also collect information on one or more process 

measures. One of these databases focuses on a practice intended to 

prevent SSIs—the routine use of antibiotics prior to surgery—and the 

other collects information on the treatment of SSIs. The ASC pilot study 

collects data solely on process measures. The most detailed data are 

provided by the two federal data sources, NHSN—the most widely 

recognized source of outcome data on HAIs—and the ASC pilot study. The 

pilot study collects data on a broad range of process measures assessing 

the implementation of infection control practices, such as those intended 

to prevent the transmission of infections through appropriate hand 

hygiene, injection, and sterilization procedures. 

NHSN Collects Clinically 

Sophisticated and 

Standardized Data on HAI 

Outcomes in ASCs, but It 

Is Not Set Up to Collect 

Nationally Representative 

Data 

A key feature of NHSN is that it collects clinically sophisticated and 

standardized data on HAI outcomes. Facilities that participate in NHSN, 

including ASCs, agree to collect and submit information on HAI outcomes, 

such as SSIs, according to defined protocols and standardized definitions. 

CDC developed detailed protocols for NHSN that specify the medical 

record and laboratory data needed to identify and categorize HAIs in 

accordance with CDC’s standardized definitions. These protocols are 

widely accepted by infection control professionals because they make the 

data in NHSN clinically relevant and comparable across the facilities 

submitting data to NHSN. At the same time, the data collection procedures 

used by NHSN can be labor intensive and technically complex for some 

users. For example, one expert reported that ASCs found data submission 

to NHSN to be time-consuming and that an ASC might opt out of the 

program if its demands on staff time and other resources became 

excessive. 

Although the number of ASCs currently submitting data to NHSN is 

unknown, it is likely to be small. NHSN has national open enrollment for 

multiple types of facilities. However, until September 2008 only hospitals 

 

18Although the Missouri state database uses definitions based on CDC criteria, it collects its 

data over the Internet through a separate, state-developed system rather than NHSN. 

Page 11 GAO-09-213 Infections in Ambulatory Surgical Centers 
 

and outpatient hemodialysis centers could enroll in NHSN.19 In September 

2008, CDC launched a new release of NHSN that enabled freestanding 

ASCs that were separate from hospitals to enroll. Enrollment of ASCs may 

increase over time, especially if more states enact programs mandating 

public reporting of HAIs by ASCs using NHSN. According to a CDC 

official, CDC has a facility survey under way that will enable it to 

determine the number of ASCs that enroll in NHSN, but this official does 

not expect to have results available from this survey until spring 2009. 

Nonetheless, independent of the number of ASCs that participate in 

NHSN, the processes by which ASCs enroll make NHSN data 

nonrepresentative of ASCs nationwide. Some ASCs enroll in NHSN 

voluntarily, and others are required to enroll by mandate of their state 

government. Because NHSN uses voluntary and mandatory selection 

procedures, the selection of ASCs for participation in NHSN is 

nonrandom. This lack of random selection precludes a projection of its 

results to any ASCs that do not participate and generalization to the 

national population of ASCs. 

ASC Pilot Study Collected 

More Detailed Information 

on HAIs in ASCs Than 

CMS’s Standard Survey 

Process Alone, but Did Not 

Collect Nationally 

Representative Data 

The ASC pilot study examined the potential for using CMS’s standard 

surveys to collect information on ASCs’ implementation of specific 

infection control practices.20 Under the pilot study, CMS modified the 

standard survey process by introducing two innovations—the 

incorporation of a CDC-developed infection control assessment tool and 

direct observation by the surveyor of a single patient’s care from start to 

finish of the patient’s stay. CDC officials also provided training for state 

surveyors on using the tool and developed plans to analyze the infection 

control data obtained with the tool. A CMS official told us that CMS would 

consider making changes to CMS’s standard survey process for ASCs after 

reviewing planned CMS and CDC analyses of the pilot study results. 

 

19According to CDC officials, a modest number of ASCs were enrolled in NHSN when 

enrollment was limited to hospitals and outpatient hemodialysis centers. These were ASCs 

within hospitals that had enrolled and entered HAI data into NHSN, but CDC cannot 

determine how many there were. The definition of ASCs that we use for this report does 

not include such surgical units within a hospital. 

20The pilot study was not solely focused on infection control, as the surveys conducted 

under the pilot study examined ASCs’ compliance with all Medicare health and safety 

standards except for the life safety standards. 

Page 12 GAO-09-213 Infections in Ambulatory Surgical Centers 
 

The surveys conducted under the pilot study collected more detailed 

information on practices that affect the risk of HAIs in ASCs than have 

previous surveys of ASCs. CMS’s current survey process requires 

surveyors to ascertain whether an ASC’s written policies and procedures 

address certain general topics pertaining to infection control.21 In doing so, 

surveyors assess the implementation of these policies and procedures and 

an ASC’s overall maintenance of a sanitary environment through direct 

observation and interviews with ASC staff. If surveyors find that either the 

content of those policies and procedures or their implementation by ASC 

staff is insufficient to meet CMS’s infection control standard, they submit a 

deficiency report to CMS that provides a detailed narrative describing the 

particular conditions or activities in the ASC that created that deficiency.22

In contrast, the pilot study’s infection control assessment tool focused on 

specific CDC-recommended infection control practices. The tool is a 

12-page document that includes dozens of specific infection control 

practices, involving such topics as environmental cleaning, disinfection, 

sterilization, and injection safety. CDC researchers who developed the tool 

included those practices that they had found were most critical for the 

prevention of HAIs in the ASC setting. CMS modified the tool to indicate 

when responses to the tool’s questions identified a violation of the ASC 

health and safety standards for infection control. During the course of the 

pilot study, surveyors recorded on the tool itself whether or not ASC staff 

appropriately implemented each of those practices, based on a 

combination of on-site interviews and observation. For each survey in the 

pilot, surveyors submitted a completed tool to CMS, along with the usual 

statements of deficiency for those ASCs where the surveyors found 

inadequate compliance with the infection control or other standards. 

Collecting completed tools for every surveyed ASC made it possible to 

produce standardized quantitative data on the extent of compliance with 

each of the practices assessed by the tool across all ASCs surveyed for the 

pilot study. The tool provides detailed guidance to surveyors on how to 

assess the implementation of these practices. In addition, the training 

provided by CDC officials on how to use the tool included the principles of 

disease transmission to prepare the state surveyors to observe ASC 

 

21These topics include methods to minimize sources and transmission of infection, 

including adequate surveillance techniques, sterilizing techniques for supplies and 

equipment, procedures for isolation, procedures for orienting new employees in infection 

control and personal hygiene, and aseptic techniques. 

22The ASC in turn must submit a corrective action plan that describes how it will remedy 

those deficiencies. 

Page 13 GAO-09-213 Infections in Ambulatory Surgical Centers 
 

practices with a “sharp eye” for serious mistakes that could lead to the 

transmission of HAIs. State officials from the pilot states reported positive 

assessments of the pilot survey process and noted that during the pilot 

surveyors observed unsafe practices that they would not have detected 

using the current survey guidance. These practices included ASC staff 

using single-use medication vials for multiple patients and failing to 

properly sterilize equipment. 

State officials reported that surveys conducted under the pilot study took 

additional time and staff resources, although specific amounts varied. In 

all three states, surveyors conducted a standard survey for a given ASC in 

addition to completing the infection control assessment tool and observing 

a patient’s care from start to finish. For the two states that had previously 

conducted standard surveys of ASCs, one found that implementing the 

pilot study’s two innovations required substantial additional staff 

resources, and the other found that, with practice, only a modest amount 

of additional resources was needed.23

CMS and CDC officials reported that they intended to separately analyze 

the results of the pilot study, each agency having a different focus. 

Specifically, a CMS official reported that CMS would analyze the effect of 

the pilot study’s innovations on CMS’s ability to assess the level of 

compliance of ASCs in the pilot states with Medicare’s health and safety 

standards, including the standard pertaining to infection control. In 

addition, from its interviews with state officials, CMS has obtained 

information on what techniques were effective for using the infection 

control assessment tool and related CDC training. CMS’s review would 

identify where lapses in infection control practices were found by 

surveyors in the pilot states and use these data to strengthen CMS’s ASC 

survey guidance, which CMS is currently in the process of updating. CDC 

officials reported that their analysis of the pilot study would focus on 

deriving a baseline understanding of how safely care was being delivered 

in ASCs, by determining the prevalence of lapses in specific infection 

control practices. These officials stated that CDC would use the analysis to 

identify “hot spots” for infection control errors for which it could target 

future recommendations and trainings. 

 

23Officials from the remaining state’s survey agency reported that although the state had 

conducted standard surveys of ASCs seeking enrollment for the first time in Medicare, it 

had not previously resurveyed any existing ASCs due to a lack of available resources. 

Page 14 GAO-09-213 Infections in Ambulatory Surgical Centers 
 

Neither CDC nor CMS officials have determined a timeline for the 

completion of their respective activities. As of October 2008, surveyors in 

the pilot states had finished their surveys and submitted the information 

they collected to CMS to be analyzed separately by CMS and CDC. 

Officials from both agencies estimated that their analyses of the survey 

results would be available in fiscal year 2009, but said they did not have 

any written plan or timeline for completing their analyses. 

A CMS official reported that agency officials planned to consider making 

some changes to CMS’s standard survey process for ASCs after reviewing 

the CMS and CDC analyses but did not intend to continue the pilot study’s 

data collection. This official reported that CMS was considering adopting 

the practice of directly observing patients from start to finish that was 

tested in the pilot study. This official also stated that CMS was considering 

whether to use the infection control assessment tool simply as a prompt 

for surveyors in assessing compliance with its infection control standard. 

The official noted that the tool provided precise guidance that had 

previously been lacking on specific practices that surveyors should 

examine in assessing compliance with the infection control standard. 

Under the pilot study, the assessment tool allowed surveyors to record 

ASC compliance with specific infection control practices in a quantifiable 

manner. In contrast, if the tool is used as a prompt, the surveyors would 

report only the instances where ASCs were found to be out of compliance 

with the standard as a whole, giving a narrative description of the reasons 

why, as they currently do under the standard survey process. CMS officials 

told us that they did not intend to continue using the tool to collect data, 

as was done in the pilot study. 

Even if CMS were to continue the pilot study’s data collection methods, it 

still would not be able to use these data to make estimates about the 

prevalence of safe and unsafe infection control practices in ASCs 

nationwide. CMS’s current policy for selecting ASCs to survey eschews 

random selection in favor of an approach that seeks to maximize the 

impact of limited survey resources, including targeting ASCs considered 

most likely to represent a greater risk for quality issues and selecting those 

Page 15 GAO-09-213 Infections in Ambulatory Surgical Centers 
 

that have not been surveyed within a given time interval.24 Specifically, in 

selecting ASCs for these surveys, CMS requires state survey agencies to 

give highest priority to ASCs that have not been surveyed in 6 years or 

more or that have had recent compliance problems. State survey agencies 

survey about half of ASCs every 3 to 4 years, but some ASCs go much 

longer between surveys—20 percent more than 6 years and 8 percent more 

than 10 years. CMS officials told us they were concerned that the level of 

ASC survey activity in recent years had not been sufficient to provide 

meaningful and current data on ASC performance across the board, 

including infection control issues. As a result, for fiscal year 2009 CMS 

increased the number of highest-priority surveys that it funded states to 

conduct on ASCs from 5 to 10 percent of ASCs each year. However, 

because this larger number of surveys does not include randomly selected 

ASCs, the results would still not provide information that could be 

generalized to ASCs nationwide. 

Experts we interviewed noted that the ASC environment presented 

challenges to the feasibility of collecting outcome data. Some of these 

challenges relate to the difficulties in identifying ASC patients who 

develop HAIs. The experts told us that patients tend to be in outpatient 

facilities for a relatively short time because ASC procedures generally take 

little time to perform. Because HAIs are not likely to develop until after a 

patient leaves an ASC, the opportunity to observe patients and collect HAI 

data is limited. The experts also told us that the opportunity to collect HAI 

outcome data might be further limited because rather than returning to the 

ASC if a complication develops following a procedure, patients often seek 

follow-up care from their primary care physician, a hospital emergency 

department, or an urgent care center. Consequently, the ASC might never 

know that an HAI occurred, and so would be unable to report it. 

Collecting Process 

Data on HAIs in ASCs 

Is More Feasible Than 

Collecting Data on 

Outcomes 

Experts noted that a general lack of infection control professionals in 

ASCs presents a challenge to the feasibility of collecting either outcome or 

process data. According to the experts, ASCs rarely have a designated 

 

24There is, however, one group of ASCs that are selected through a generally random 

process. State survey agencies conduct surveys on a CMS-selected sample of accredited 

ASCs to validate the accrediting organizations’ survey results. According to CMS officials, 

approximately 18 percent of Medicare-certified ASCs are accredited, which means they are 

inspected by the accrediting organizations rather than the state survey agencies to 

determine compliance with Medicare requirements. Accreditation surveys take place 

approximately every 2 to 3 years, depending on the accrediting organization. 

Page 16 GAO-09-213 Infections in Ambulatory Surgical Centers 
 

infection control professional, which is a health care worker trained to 

lead infection control efforts in a health care facility.25 CDC officials told 

us that, as with NHSN, data collection for HAIs has been historically 

designed for hospitals with the understanding that, unlike most ASCs, 

hospitals have infection control professionals responsible for collecting 

such data. The lack of such an individual presents a challenge to the 

feasibility of collecting either type of data, especially when such data are 

technically complex or the data collection processes are labor intensive. 

Employing an infection control professional would require ASCs to devote 

time and resources to an area that they have traditionally thought to be 

low risk. 

The experts we interviewed generally agreed that collecting process data 

on HAIs in ASCs is more feasible and potentially more useful than 

collecting data on outcomes. Several experts said it was more feasible to 

collect data on HAIs by focusing on process measures rather than 

outcome measures because unsafe practices may be observed with less 

effort and technical training than is needed to identify individual cases of 

HAIs. A CMS official reported that because of the relatively short time that 

patients are in the facility, the ASC environment lends itself well to the 

methodology of tracing a patient through his or her entire experience at 

the ASC as a means for observing specific practices, such as those related 

to infection control. The experts also noted that gathering such process 

data could provide useful guidance to ASCs. For example, such data could 

point to areas for specific remedial training on preventive activities, such 

as training on the proper use of single-dose vials and the appropriate 

procedures for sterilizing equipment. 

The increasing volume of procedures and evidence of infection control 

lapses in ASCs create a compelling need for current and nationally 

representative data on HAIs in ASCs in order to reduce their risk. Because 

HAIs generally only occur after a patient has left an ASC, data on the 

occurrence of these infections—outcome data—are difficult to collect. But 

data on the implementation of CDC-recommended infection control 

practices—process data—in ASCs can be collected more easily and can 

provide critical information on why HAIs are occurring and what can be 

done to help prevent them. 

Conclusions 

 

25Infection control professionals identify cases of HAIs and promote infection control 

practices to help reduce the occurrence and spread of HAIs. 

Page 17 GAO-09-213 Infections in Ambulatory Surgical Centers 
 

One federal data source, the ASC pilot study, has shown the potential for 

using process data to increase the understanding of HAIs in ASCs. The 

pilot study tested the addition of an infection control assessment tool to 

collect detailed data on recommended practices during the course of a 

CMS standard survey. With the tool, specially trained state surveyors were 

able to identify serious lapses in recommended practices. Such lapses, 

which increased patients’ risks of developing HAIs, had not previously 

been detected through CMS’s standard surveys. The pilot study had the 

added benefit of not relying on ASCs to submit HAI data themselves with 

their limited staff resources. 

The results of the ASC pilot study demonstrate the feasibility of collecting 

data on the prevalence of specific infection control practices while 

conducting surveys of ASCs. Although detailed analyses of the data 

obtained during the pilot by CDC and CMS are pending, officials in the 

three pilot states and at CMS uniformly reported positive assessments of 

the process developed by CMS and CDC to collect these data during the 

course of standard ASC surveys by state surveyors. However, CMS has no 

plans to continue collecting such data following the completion of the ASC 

pilot surveys. If CMS and CDC do not build on their experiences with and 

analyses of the pilot to continue collecting such data from a subset of ASC 

surveys using an instrument such as the infection control assessment tool, 

then HHS is losing an opportunity to take advantage of the existing ASC 

survey process to collect information on the prevalence of infection 

control practices on an ongoing basis. 

Collecting detailed data on the prevalence of infection control practices is 

only part of what is needed to increase the understanding of the problem 

of HAIs in ASCs nationwide. The ability of HHS to use CMS’s standard 

survey process to collect nationally representative process data on 

infection control practices in ASCs and to make estimates about the 

prevalence of safe and unsafe infection control practices in ASCs 

nationwide also depends on introducing random selection for ASC 

surveys. The larger the number of randomly selected ASCs surveyed, the 

greater the precision that would be achieved for those results. For 

standard surveys, CMS currently selects those ASCs deemed most likely to 

have quality problems or that have not been surveyed within a given time 

interval and does not select any randomly from the national population of 

ASCs. However, CMS has recently expanded the number of ASC surveys 

that it conducts, and HHS could choose to have CMS select some ASCs 

randomly for standard surveys while continuing to target others. In 

determining the number of ASCs to be randomly selected, HHS could 

weigh the value of obtaining more precise information from a larger 

Page 18 GAO-09-213 Infections in Ambulatory Surgical Centers 
 

number of randomly selected ASCs against the value of targeting surveys 

to those ASCs that may be more likely to have quality deficiencies. HHS 

could determine the number of ASCs it would need to select at random to 

generate meaningful national estimates to help identify where lapses in 

infection control practices by ASCs across the country were most likely to 

be putting patients at risk of contracting HAIs. 

To obtain nationally representative and standardized information on the 

extent to which ASCs implement specific infection control practices that 

reduce the risk of transmitting HAIs to their patients, we recommend that 

the Acting Secretary of HHS develop and implement a written plan to use 

the data collection instrument and methodology tested in the ASC pilot 

study, with appropriate modifications based on the CDC and CMS analyses 

of that study, to conduct recurring periodic surveys of randomly selected 

ASCs. 

We provided a draft of this report to HHS for comment. In response, the 

Acting Administrator of CMS provided written comments, and we have 

reproduced these comments in appendix I. CMS also provided technical 

comments, which we have incorporated as appropriate. 

Recommendation for 

Executive Action 

Agency Comments 

In its written comments, CMS stated that it concurred with our 

recommendation to HHS. CMS stated that it would use the results from the 

pilot study to evaluate the value and feasibility of incorporating the 

infection control assessment tool into the standard ASC survey process. 

The agency stated that if its evaluation resulted in a decision to use the 

infection control survey tool on an ongoing basis, then it would explore 

with CDC whether CDC would be able to continue to provide training and 

data analysis of the completed infection control assessment tools, as CDC 

did for the pilot study. Given such support from CDC, CMS stated that it 

would be willing to establish a process for randomly selecting at least 

some ASCs in each state for ASC surveys. We agree that implementing our 

recommendation requires analysis of the pilot study to determine 

appropriate modifications to the data collection tool and collaboration 

within HHS. However, given the risks of HAIs in ASCs and the compelling 

need for current and nationally representative data on them, it is 

important that the department follow our recommendation to develop and 

implement a written plan to ensure that it collects such data using 

recurring periodic surveys of randomly selected ASCs. 

Page 19 GAO-09-213 Infections in Ambulatory Surgical Centers 
 

As agreed with your offices, unless you publicly announce the contents of 

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charge on the GAO Web site at http://www.gao.gov. 

If you or your staffs have any questions about this report, please contact 

me at (202) 512-7114 or bascettac@gao.gov. Contact points for our Offices 

of Congressional Relations and Public Affairs may be found on the last 

page of this report. GAO staff who made major contributions to this report 

Cynthia A. Bascetta 

are listed in appendix II. 

Director, Health Care 

Page 20 GAO-09-213 Infections in Ambulatory Surgical Centers 
List of Congressional Requesters 

The Honorable Henry Waxman 

Chairman 

Committee on Energy and Commerce 

House of Representatives 

The Honorable Frank Pallone, Jr. 

Chairman 

Subcommittee on Health 

Committee on Energy and Commerce 

House of Representatives 

The Honorable Shelley Berkley 

House of Representatives 

Page 21 GAO-09-213 Infections in Ambulatory Surgical Centers 
Appendix I: Comments from the Centers for Appendix I: Comments from the Centers for Medicare & Medicaid Services 

Medicare & Medicaid Services 

Page 22 GAO-09-213 Infections in Ambulatory Surgical Centers 
Appendix I: Comments from the Centers for 

Medicare & Medicaid Services 

Page 23 GAO-09-213 Infections in Ambulatory Surgical Centers 
Appendix I: Comments from the Centers for 

Medicare & Medicaid Services 

Page 24 GAO-09-213 Infections in Ambulatory Surgical Centers 
Appendix II: 

A

GAO Contact and Staff 

cknowledgments 

Page 25 GAO-09-213 

Appendix II: GAO Contact and Staff 

Acknowledgments 

GAO Contact Cynthia A. Bascetta at (202) 512-7114 or bascettac@gao.gov

In addition to the contact named above, key contributors to this report 

were William Simerl, Assistant Director; Jennel Harvey; Eric Peterson; 

Roseanne Price; and Andrea E. Richardson. 

 Infections in Ambulatory Surgical Centers 

Acknowledgments 

(290716) 
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