accreditation
TRANSCRIPT
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Who do you want to accredit?
A. The hospital as a whole – with regard to infec=on control
B. The Infec=on Control unit
Both works – depending on how broad you evaluate the seFng in which the IC unit operates
Na=onal IC guidelines Norm with regard to size and structure of IC units
¤ Na=onal IC guidelines ¤ Norm with regard to size and structure of IC units ¤ Recognized training for ICP & MD’s ¤ Laws with regard to CME ¤ Laws with regard to transmissible diseases ¤ Inspectorate
² An authority that can penalize non-‐conforming healthcare ins=tu=ons
¤ Risk of acquiring preventable infec=ons due to breaks in preven=ve measures ² Guidelines implementa=on & behavioral change
¤ An=microbial resistance impeding pa=ent’s safety ² Interrupt transmission of MDROs ² An=microbial stewardship
Indicators need to asses the above!
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¤ Structure
¤ Process
¤ Outcome
¤ to ensure that the infec=on control team is geFng the necessary funding to adequately do their work in a seFng that commits to pa=ents safety aspects
Important indicator, but ² Par=cular considera=on needed ² Major piXalls -‐ weighing of individual steps of the process. • “A chain is only as strong as it’s weakest link” is not correct for many processes!
Process if okay, but outcome is what it’s all about
¤ Incidence of defined MDRO in blood-‐cultures per 100,000 days at risk ² Overall admisson days of the hospital -‐ (2 x admissions)
¤ Environmental cleaning ² final cleaning a`er discharge of isola=on pa=ent check with microbiology or ATP
¤ Hand hygiene ² WHO method or compliance rate
Please – No more!
Medicine 2015 Paper work instead of work with pa=ents
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¤ Easy to collect ² Extractable from LIS and HIS ² App support
¤ Clearly and well defined ² Everyone really measuring the same, comparable between different hospitals
¤ Immediately accessible for the user ² Guide interven=ons
Do not allow non-professionals to formulate them ���
MD*
*lead
ICP ICP
ICT
Inspec- ���torate
Willemsen et al Antmicrob Resistance Infect Control 2014;3:26
Crosssec8onal surveillance of: ¤ Two outcome variables:
² Prevalence of HAI (SSI, LRTI, UTI, GI, bacterial conjunc=vi=s) ² prevalence of rectal carriage of ESBL producing Enterobacteriacea
¤ Two resident-‐related risk factors: ² prevalence of medical device ² prevalence of an=microbial therapy
¤ Three ward-‐related risk factors: ² environmental contamina=on ² shortcomings in infec=on preven=on precondi=ons ² availability of local infec=on preven=on guidelines
Willemsen et al Antmicrob Resistance Infect Control 2014;3:26
¤ For each outcome variable or risk factor, breakpoints were set to make the division in 3 categories ² low, intermediate and high
² Classifica=on based on na=onal prevalence surveys, scien=fic publica=ons and if no data was available on expert opinion
¤ Popula=on characteris=cs get considered Willemsen et al Antmicrob Resistance Infect Control 2014;3:26 Willemsen et al Antmicrob Resistance Infect Control 2014;3:26
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¤ Infec=ons in NH ¤ Intravenous administra=on ¤ Medicine administra=on ¤ Cleaning/disinfec=on and
steriliza=on ¤ Storage of sterile materials ¤ Waste collec=on and transport ¤ Urine drainage and defeca=on ¤ Care of airways ¤ Wound care ¤ Tube feeding
¤ MDRO/MRSA ¤ Norovirus ¤ Scabies ¤ Legionella control ¤ Food safety ¤ Pets in the NH ¤ Registra=on of ID ¤ Hand hygiëne ¤ PPE ¤ Personal hygiene ¤ Personnel ID & blood exp
Willemsen et al Antmicrob Resistance Infect Control 2014;3:26
¤ Bathroom sink ¤ Bedside cabinet ¤ Table living room ¤ Microwave kitchen ¤ Bedside commode ¤ U=lity room ¤ Sterile storage shelve ¤ Toilet seat ¤ Washing bowl Willemsen et al Antmicrob Resistance Infect Control 2014;3:26
¤ Availability of hand alcohol ¤ Availability of gloves, gowns, masks ¤ Availability of needle container ¤ Availability of bedpan washer ¤ Availability of plas=c aprons ¤ Presence of at least one HH sink per 15 residents ¤ Presence of at least wo toilet groups per 15 residents ¤ Presence of at least one single room with bathroom per 15 residents
Willemsen et al Antmicrob Resistance Infect Control 2014;3:26 Willemsen et al Antmicrob Resistance Infect Control 2014;3:26
Willemsen et al Antmicrob Resistance Infect Control 2014;3:26
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Dutch Society of ICP
Dutch Society of Medical Microbiology
Quality & Visita8on commiEee (2006)
¤ Aiming at the work of the infec=on control team/unit – not the hospital as a whole
¤ Audits are done by ICPs and IC-‐MDs ¤ The audit is based on interna=onal and na=onal laws and guidelines, including ISO 14001 and OHSAS 18001
¤ Uses Plan-‐Do-‐Check-‐Act (PDCA) principles
The quality criteria are defined as: ¤ Norms = must haves ¤ Points of anen=on( POA) = the minimum norms (checkable via quick-‐scan)
¤ Addi=onal points = want to haves
1. Mission and vison 2. Strategy & Aims 3. Work of the IC unit 4. Human resource aspects 5. Finances 6. Housing 7. Internal Quality Control
Norm ¤ Unit has a vision and mission POA ¤ Present on paper ¤ Only one vision and mission ¤ Concurrent with hospital V&M ¤ The ambi=on formed by V&M should be known to others
¤ Quality system ¤ Strategy planning & report
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Norm ¤ Quality system designed, documented and implemented
PAO ¤ Complete Quality Manual ¤ Inten=on to cooperate documented ¤ Scope defined ¤ Responsibili=es of controlling groups documented
Norm ¤ Strategy and according aims are formulated and supported (FTE, $)
¤ Responsibili=es formulated POA ¤ Mul=-‐year strategy plan present ¤ Year plan present
² SMART-‐formulated ² corresponding with mul=-‐year plan ² Controlled planning and achievements ² Safety, integrity, privacy, communica=on
Norm ¤ Clear descrip=on of responsibili=es and what the unit is doing
POA ¤ What are the primary tasks – documented ¤ “Customers” know what the tasks are ¤ Tasks are priori=zed ¤ Possible overlap with technical services, cleaning, CSD, … described
I skip the next 7 slides but they are online
¤ Surveillance and implementa=on of improvement IC guidelines based on na=onal laws/guidelines
¤ Outbreak management ¤ Training ¤ Audits ¤ Consultancy ¤ Cleaning, disinfec=on, steriliza=on ¤ Construc=on ¤ Control of water and air ¤ Buying of disposables & othet biomedical products ¤ Research
Norm ¤ Posi=on and hirachical and func=on management of units is described
POA ¤ Organogram present ¤ SLA with external organisa=ons ¤ Par=cipa=on in comminees (internal & extermal) ¤ Communica=on and exchange of informa=on with microbiology lab
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1. Mission and vison 2. Strategy & Aims 3. Work of the IC unit 4. Human resource aspects 5. Finances 6. Housing 7. Goods 8. Internal Quality Control
¤ Internal structure and responsibility ¤ Descrip=on of the professional func=ons ¤ Overview of individuals tasks and addi=onal/external work
¤ Planning (free, on-‐duty, …) including con=nuity in the work and communica=on/reachability
¤ SOPs ² New co-‐worker, (cont.) eductaion/training, size of the unit, guidline with regard to part-‐=me work, …
¤ Yearly professional evalua=on of each co-‐worker
¤ Independence of the unit ¤ Document who is responsible for finances – budget control
¤ Contracts and SLAs ¤ Insurances
¤ Close to wards ¤ Adequate rooms
² including telephones, computers, printers, …
¤ Access to all systems (LIS, HIS, OR ystem, …) ¤ Safety aspects
¤ Documents and archives ¤ Internal and external quality control of the unit ¤ Management review
¤ Lots of good stuff, and probably needed for an accredita=on, best we have, but …
¤ Very theore=cal Long and a lot of work ¤ Addi=onal to professional audit by peers – instead of integrated
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We can’t make it fun, but we do our best to make it prac=cal and easy