health center infection control · 7/19/2019 · apic infection control risk assessment tool...

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Health Center Infection Control

Lorrie Cappellino, RN, MSAmbulatory Surveyor, The Joint Commission

July 19, 2019

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Health CenterInfection Control (IC)

PurposeBackground InformationIC Risk AssessmentIC PlanTargeted health center IC toolQ&A

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Purpose of Today’s PresentationMake good on our commitments to you

– Be a collegial/collaborative partner– Be transparent– Help identify risks– Be educational

Additionally – Help enhance quality/safe patient care – Help identify/reduce process problems– Help improve organizational success– Inspire your organization to improve/excel

Presenter

Presentation Notes

Lot of resources on our website: booster packs…most challenging standards…to help you

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The Joint Commission’s Mission

To continuously improve health care for the public, in collaboration with other stakeholders, by

evaluating health care organizations and inspiring them to excel in providing safe and

effective care of the highest quality and value.

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The Joint Commission’s Vision

All people always experience the safest, highest quality, best-value health care across

all settings.

Presenter

Presentation Notes

Pretty lofty. We’re united by an enterprise vision statement that is far more than just words on a page or website. Its an aspiration. A roadmap of where we want to be. An unrelenting commitment.

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Our Organizing Principle

Leading the Way to Zero

Presenter

Presentation Notes

If you’re reading the “Perspectives” from the Joint Commission… We’re still missing something… We cannot be satisfied with elevating the highest standards in the industry if preventable harm still occurs.

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Imagine a Day of Zero

Zero complications of careZero missed opportunitiesZero overuseZero harmZero lost revenueZero harm events of any kind

Presenter

Presentation Notes

This means improved efficiency and care. A day full of pride. A day full of healing. A day full of zeros. Ex: Antibiotic usage and opioid abuse.

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8Information relates to health center TJC reports dated 2/13/2017 – 9/5/2018; multiple IC topics may have been referenced under each finding; excludes APR findings

Presenter

Presentation Notes

APR finding information excluded because the information was included elsewhere in the report. “Decontamination” includes topics such as problems with: transport of used items, biohazard labels, using the wrong product, incorrect mixing/measurement of disinfectant/products, improper use of brushes, water temp issues, etc. “Processing” includes topics such as problems with: improper packages, items in closed position, peel pouch issues, no chemical indicators used “Following IFU/EBPs” includes not only following these guidelines, but not selecting/having guidelines for use “Leadership” includes leadership findings, lack of oversight and lack of training of leaders overseeing IC, sterilization, HLD processes “Other” includes: PPE, Neg Air testing, MDV usage, dental multi-use dispenser and hand hygiene

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Organization’s IC Program

IC Risk Assessment + IC Plan = foundation of the IC Program

Risk Assessment is the starting pointUse the risk assessment to identify important

issues for your organizationCreate IC Plan that includes goals for your

health center IC Program should be meaningful and

individualized for your health center

Presenter

Presentation Notes

Tied to: Mission/vision of the Org Lot of resources on our website: booster packs…most challenging standards…

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IC Risk Assessment

Identifies risks for transmitting infections

Assists in focusing surveillance and other regulatory activities

Risks are identified annually and when changes occur

Presenter

Presentation Notes

Individualized to each organization Reviewed/redone each year Approved by governing board A facility risk assessment is conducted by identifying and reviewing potential risk factors for infection related to the care, treatment, and services provided and to the environment of care in a specific healthcare setting. The identified risks of greatest importance and urgency are then selected and prioritized. Based on these identified risks, facility personnel should develop the organization’s Infection Surveillance, Prevention and Control Plan (i.e., an action plan).

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IC Risk AssessmentFactors to Include

Geographic locationEnvironment concernsPopulation servedArea endemic concernsCare, treatment and services providedRegulatory/state specific requirements

Presenter

Presentation Notes

Individualized to each organization Reviewed/redone each year Approved by governing board Immigrant/ Migrant workers Nursing Home Patients Incarcerated patients Homeless Immunocompromised pts such as transplant and chemotherapy pts Other: __________________________________________ Patients with MDRO’s – MRSA, VRE, etc. Patients with C-Diff. or other Communicable Diseases in the last year Current health concerns in community �TB HIV/AIDS Hepatitis B & C MRSA, VRE Staph C. diff Other: ______________________________ � State specific legislation MRSA Legislation Infection Control Certification Certified Central Sterile Processor

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Assign Values Based on Risk

Probability of event occurring– Known risk, historical info, research data

Impact/severity– Threat to life, service impact, financial loss

Current system– Training status, policies, back-up systems

Rank order risk

Presenter

Presentation Notes

Will show a sample template…easy to use Assign value based on risk

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Assign Values Based on Risk

Score each itemRank order using risk scaleEach organization’s priorities will be

different

Presenter

Presentation Notes

Assess and score each potential risk factor based on the following: Potential impact of the event/condition on patients and personnel, determined by evaluating the potential for patient illness, injury, infection, death, need for admission to an inpatient facility; the potential for personnel illness, injury, infection, shortage; potential to impact the organization’s ability to function/remain open; and degree of clinical and financial impact. Probability of the event/condition occurring determined by evaluating the risk of the potential threat actually occurring. Information regarding historical data, infection surveillance data, the scope of services provided by the facility, and the environment of the surrounding area (topography, interstate roads, chemical plants, railroad, ports, etc.) are considered when determining this score. Organization’s preparedness to deal with the event/condition determined by considering policies and procedures already in place, staff experience and response to actual situations, and available services and equipment. After risk scores are assigned in the three assessment groups, total the numbers in each group to provide a numerical risk level for each event/ condition. Rank the events/conditions from the highest to lowest score in the table provided. Select the risks with the highest scores for priority focus for developing the annual IC Plan. (Reference: APIC)

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APIC Sample Risk

Assessment Tooland

Examples for Health Centers

Infection Control Risk Assessment, APIC

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APIC Infection Control Risk Assessment Tool (Fillable)

Presenter

Presentation Notes

Fillable tool can be found on-line – see reference page for website

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APIC Infection Control Risk Assessment Tool Health Center Examples

Presenter

Presentation Notes

A simple example for health centers…all centers will be individualized

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Sample IC Prioritized RisksHealth Center Examples

Risk #1: Hand Hygiene Compliance (scored a 7 on the risk assessment)

Risk #2: Instrument Decontamination Processing Compliance (scored a 7 on the risk assessment)

Risk #3: Flu Vaccine Compliance(scored a 6 on the risk assessment)

Risk #4: Dental Site Infection Rate(scored a 5 on the risk assessment)

Presenter

Presentation Notes

The risk assessment and IC Plan should be reviewed and approved by the organization’s quality assurance and performance improvement committee (or other designated committee). The risk assessment and IC Plan should be reviewed annually (and sooner if circumstances change). (APIC)

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Infection Control Plan

Based on prioritized risks (from risk assessment)

Includes measurable goalsIncludes strategies for implementationPlan is written and evaluated annually

Presenter

Presentation Notes

Use risk assessment to create plan. Plan is evaluated annually, reported up and down chain Plan includes IC goals for the Org Renew plan each year The risk assessment and IC Plan should be reviewed and approved by the organization’s quality assurance and performance improvement committee (or other designated committee). The risk assessment and IC Plan should be reviewed annually (and sooner if circumstances change). (APIC)

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Infection Control Plan

Rank order prioritiesUse top risks/highest priorities to set

goals (3/4/5?)Goals are broad statementsDevelop measurable objective for each

goalDesign steps (strategy) to meet goalDetermine how you will measure

success (meet goal)

Presenter

Presentation Notes

Measurable objectives – Improve hand hygiene – measurable – Example: “hand hygiene over 80%” Focus on important/high priority items. Don’t attempt to have too many…or the org will lose focus of priorities.

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Risk Assessment and Plan Done with Interdisciplinary Input

Medical providersDental providersAdministratorsNursingStaff from sterilization/HLD departmentLeadersEmployee healthOthers

Presenter

Presentation Notes

The risk assessment and IC Plan should be reviewed and approved by the organization’s quality assurance and performance improvement committee (or other designated committee). The risk assessment and IC Plan should be reviewed annually (and sooner if circumstances change). (APIC)

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Risk #1: Hand Hygiene Compliance Risk #2: Instrument Decontamination

Processing Compliance Risk #3: Flu Vaccine ComplianceRisk #4: Dental Site Infection Rate

Sample IC Prioritized RisksHealth Center Examples

Presenter

Presentation Notes

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Health Center IC Goals ExamplesTime Frame, Make Measurable

Goal Risk #1: To improve hand hygiene guideline compliance rate to 75%

Goal Risk #2: To improve instrument decontamination processing compliance to 98%

Goal Risk #3: To increase annual flu vaccine compliance rate to 90%

Goal Risk #4: To reduce dental site infection rate to 0.01%

Presenter

Presentation Notes

Examples of written, measurable goals for a health org. Ensure they are easily understandable and based on priorities from risk assessment

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Health Center Infection Control

Tool/Checklist

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Presenter

Presentation Notes

Tool is fillable. Can be adjusted as work is accomplished/training occurs/resources change/processes are adjusted. Recommended reviewing checklist on a recurring basis and at least annually. May be used as a prep tool and to help keep on track for quality/safety purposes. Resources Utilized: �APIC CDC AORN SGNA ASPAN AAMI Local Health Department Specialty specific organizations

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Infection Control References 2008 CDC Guideline for Disinfection and Sterilization in Healthcare Facilities.”

Centers for Disease Control and Prevention

2018 Association of Perioperative Registered Nurses, AORN Guidelines for Perioperative Practice

American Dental Association (ADA) Policy Statement on Infection Control in the Practice of Dentistry - https://www.ada.org/en/member-center/oral-health-topics/infection-control-resources

ANSI/AAMI ST58, Chemical sterilization and high-level disinfection in health care facilities https://my.aami.org/aamiresources/previewfiles/ST58_1308_preview.pdf

ANSI/AAMI ST79, Comprehensive guide to steam sterilization and sterility assurance in health care facilitieshttps://my.aami.org/aamiresources/previewfiles/1709_ST79Preview.pdf

ANSI/AAMI ST91, Flexible and semi-rigid endoscope processing in healthcarehttps://www.aami.org/productspublications/ProductDetail.aspx?ItemNumber=2477

http://www.ada.org/1851.aspx

https://www.ada.org/en/member-center/oral-health-topics/infection-control-resources

https://my.aami.org/aamiresources/previewfiles/ST58_1308_preview.pdf

https://my.aami.org/aamiresources/previewfiles/1709_ST79Preview.pdf

https://www.aami.org/productspublications/ProductDetail.aspx?ItemNumber=2477

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Infection Control References

APIC Infection Control Risk Assessment Templatehttps://www.google.com/search?q=apic+infection+control+risk+assessment&rlz=1C1GCEU_enUS826US826&oq=APIC+Infection+Control+Risk+Assessment&aqs=chrome.0.0l2.11136j0j9&sourceid=chrome&ie=UTF-8

APIC Infection Control Risk Assessment Examplehttps://apic.org/Resource_/TinyMceFileManager/Academy/ASC_101_resources/Risk_Assessment/Risk_Assessment_Example_2.docx

APIC Text of Infection Control and Epidemiology. 4th Edition. 2014

CDC Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care (Both the guide and checklist).https://www.cdc.gov/hai/settings/outpatient/outpatient-care-guidelines.html

“Cleaning, Disinfection and Sterilization,” APIC Text on Infection Control and Epidemiology http://text.apic.org.eu1.proxy.openathens.net/toc/basic-principles-of-infection-prevention-practice/cleaning-disinfection-and-sterilization

https://www.google.com/search?q=apic+infection+control+risk+assessment&rlz=1C1GCEU_enUS826US826&oq=APIC+Infection+Control+Risk+Assessment&aqs=chrome.0.0l2.11136j0j9&sourceid=chrome&ie=UTF-8

https://apic.org/Resource_/TinyMceFileManager/Academy/ASC_101_resources/Risk_Assessment/Risk_Assessment_Example_2.docx

https://www.cdc.gov/hai/settings/outpatient/outpatient-care-guidelines.html

http://text.apic.org.eu1.proxy.openathens.net/toc/basic-principles-of-infection-prevention-practice/cleaning-disinfection-and-sterilization

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Infection Control References

IAHCSMM educational materials: www.iahcsmm.org/education/online-lessons.html

“Infection Prevention Checklist for Dental Settings Basic Expectations for Safe Care,”https://www.cdc.gov/oralhealth/infectioncontrol/pdf/safe-care-checklist.pdf

Recommendations from the Guidelines for Infection Control in Dental Healthcare Settings – 2003. https://www.cdc.gov/oralhealth/infectioncontrol/pdf/recommendations-excerpt.pdf

The Joint Commission High Level Disinfection and Sterilization Booster Pack: https://www.jointcommission.org/assets/1/6/TJC_HLD_BoosterPak.pdf

“Using the Risk Assessment to Set Goals and Develop the Infection Prevention and Control Plan.” Joint Commission Resourceshttps://www.jcrinc.com/using-the-risk-assessment-to-set-goals-and-develop-the-infection-prevention-and-control-plan/

http://www.iahcsmm.org/education/online-lessons.html

https://www.cdc.gov/oralhealth/infectioncontrol/pdf/safe-care-checklist.pdf

https://www.jointcommission.org/assets/1/6/TJC_HLD_BoosterPak.pdf

https://www.jcrinc.com/using-the-risk-assessment-to-set-goals-and-develop-the-infection-prevention-and-control-plan/

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Health CenterInfection Control (IC)

PurposeBackground InformationIC Risk AssessmentIC PlanTargeted health center IC toolQ&A

health center infection control · 7/19/2019 · apic infection control risk assessment tool...

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