DNV GL Healthcare · The DNV GL surveyors apply a comprehensive 18-point standard, with each element representing known trigger points fo\൲ infection risk.\爀屲The process is
Who is DNV GL Healthcare: DNV GL has an extensive background in risk management and has worked with many hospitals and world leading agencies in research, diagnosis and management of infectious disease in Europe, Asia and North America. They are a dedicated team of experts with experience in the operation of clinical and scientific environments and have developed a practical and effective approach to managing infection risk. Since 2008 they have been the leading innovator in US hospital accreditation, now accrediating over 600 hospitals
Hi everyone, I’m glad you could make it to DNVGLs webinar on Mitigating Infection Risk also called MIR. I’m your speaker today my name is Linda Spaulding and I am a MIR auditor as well as a NAIHO surveyor. For those of you who are not familiar with DNVGL the easiest way to describe us is the Joint Commissions competition. DNVGL provides hospital accreditation in the U.S. as well as hospitals certifications in infection risk, stroke, and hips and knees. Today I want to introduce you to a new hospital certification called MIR.
DNV GL Healthcare is a US corporation, wholly-owned by DNV GL DNV GL issued globally over 75,000 certificates to various ISO MS Standards How are we unique in how we have been able to apply learnings from other industry sectors we are involved with and how can we really use an undustry approach to the survey process while still maintaining accountability and working to improve the hospitals we work with to deliver great care to the patients they serve. Multi fold approach 1 Meet CMS conditions of participation 2- Introduce the concept of the Quality Management System aligned with ISO 9001 which leads to improved operational aspects for the organization 3-Doing this in a way we can really partner with the hospitals and we can still hold the hospitals accountable for meeting requirements and expectations However we can serve as a guide and collaborative entity and really c.arry out this process in way that is beneficial to hospitals
Solid financial background No single majority group can have control of the foundation Tell little more about changing the Culture of Accreditation and what we mean by that but it is first important to understand DNVGL and what we do The broader scope it that we are a risk management company regardless of the industry, aerospace, energy, oil and gas, food our abjective is to reduce uncertainty and increase safety for all parties involved whether that be customers, patients, staff. First and foremost we are mitigating risk we also improve efficiency. How can we foster development in the hospital and change in the way of thinking we are able to do this with ISO 9001 which enable sustainability One thing that got us into this was prepping hospitals for JC We saw hosiptals making improvements but we really did not have a structure to sustain over time so we revisit the same issues. So how do we build consistency and build trust. We are accountable to CMS to ensure our hospitals are meeting the standards and develop an accreditation program to that affect. We hold hospitals accountable in a different way. We build trust in the communities we serve.
Proactively manage and reduce risk associated with HAI’s within the organization
Reduce potential harm to patients, visitors, staff and the environment
Improve MIR performance beyond legislative requirements.
Promote continual improvement
Enable you to assure stakeholders of responsible and proportionate infection risk management
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So lets look at what the MIR standard is designed to do. MIR is designed to define the scope for managing infection risks in the healthcare setting. It facilitate the identification of current best practice, and allows for a variety of solutions to manage risk, the standard continuously drives facilities to improvement their processes, and it enables hospitals to include all departments throughout the hospital in preventing infections.
– Consistent with other international standards (e.g. ISO 9001/14001 and OHSAS 18001)
– Combines best practice from other industries with international standards
Includes elements specific for healthcare settings – Management
– Clinical
– Support
– Design
– Operation, maintenance and engineering
– Requirements from Infection prevention and control (IPC) management
– Performance management addressing quality and safety
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MIR Certification follow a path very similar to hospital accreditation. A team of MIR surveyors will visit your hospital with the exact number of auditors and length of audit determined by the scale of the hospital’s facilities, workforce and patient population. The DNV GL surveyors apply a comprehensive 18-point standard, with each element representing known trigger points for infection risk. The process is designed to pinpoint the gaps in your cross-function and inter-department workflows to help you improve your processes and help save lives.
Organizations need to provide assurance that risk is being managed effectively and proportionately
Demonstrate management holds responsibility to ensure risk is managed
Activities are proactively planned, conducted and reviewed
Integrates controls related to engineering, instructions and people
Necessary links are in place between related and dependent activities – i.e. is there a systematic process approach
Workers understand and follow the system to the required level
The system is ‘alive’ – it evolves and develops in a controlled and proactive manner
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The rationale behind the 18 elements of MIR is the need to provide assurance that risk related to infections is being managed effectively and proportionately. This doesn’t mean the IP has to be doing all of the work. It does encourage management to be responsible to ensure all risk is being managed appropriately. MIR is designed to assure that there are systematic approaches in place to successfully manage all types of infection risk. So this process is always “alive” it continues to evolve and develop over time in a controlled proactive way.
Now I’m going to take you through some of the elements to give you an idea of what the certification is all about. This presentation is meant to just give you a quick overview of some of the elements.
Roles, responsibilities and authorities (5.1.6) Top management
Management representative
Managing infection risk (MIR) committee
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System and policy in place to manage infection risks. Effective management and organization, management commitment and
leadership.
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Risk management system: Assesses whether you have established, documented and implemented an infection risk management system appropriate to the size and scope of services your hospital provides. Your Risk management policies are reviewed to be sure they clearly state the overall infection risk management objectives and there is a committement to improving your overall infection prevention program. Do you have written objectives and targets for controlling infection risk and have they been implemented and evaluated. Are there procedures in place to determine what resources are needed and are they provided. We would expect to see a statement in your Quality plan stating top management has taken ultimate responsibility for the organization’s infection risk management system. We would look to see who is the top management representative on you IP committee (MIR committee). This slide only shows you 6 of the 21 clauses in this element. So can see it’s a very extensive though look into the infrastructure of your program
Are effective mechanisms implemented to identify, assess and manage risks? Fundamental basis underpinning the MIR standard.
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It addresses how infection risk is identified, measured, monitored, mitigated and communicated. We look to see if there is a procedure in place to ensure that there is a comprehensive risk assessment system in established, implemented and maintained for all relevant activities related to infection risk. How often is it evaluated. Is it a live document reviewed at each of your IP meeting to determine if it is still up to date. Ex. AB on admission, water outage, norovirus outbreak, new respiratory infection in children that has spread to at least 7 states so far this year.
Infection surveillance program – Establish and maintain procedures
– Identify and implement measures for an effective infection surveillance program
– Identify and implement measures for an effective environmental surveillance program
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Looking at the awareness and measurement of infection risk data and trends in the hospitals. An essential measure to ensure performance is monitored and improved to effectively drive and target preventive
and response activities.
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Microbial surveillance with the third element which addresses the need to monitor infection trends in order to understand their prevalence, together with the effectiveness of prevention measures. Such measures are essential in ensuring MIR preventive and response strategies are effectively planned, implemented and reviewed.
minimization and appropriate selection of antimicrobials
- Use of antimicrobials is effectively identified, specified, dispensed and monitored with regard to infection risk
- Establish an antimicrobial use committee
- Defined role and functions
Microbiology laboratory - Identify and have access to
appropriate microbiological laboratories
Use of antimicrobial in a responsible and sustainable manner.
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Antimicrobial use and surveillance looks at how the use of antibiotics and other antimicrobials is planned, delivered and monitored in a responsible and sustainable manner.
Emergency exercises and stimulations Contingency plans
Structures and mechanisms in place to cope with working outside the normal operating conditions
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is related to emergency response and contingency planning addresses a range of measures which need to be in place, including the need for good planning, availability or physical infrastructure, capacity in terms of personnel, emergency communications, decision making authorities, and testing of scenarios and simulations.
elements or a situation which raises significant doubt that the services will meet specified requirements;
A group of category 2 NC’s indicating inadequate implementation or effectiveness of the system relevant to a requirement of the standard;
A category 2 NC that is persistent (or not corrected as agreed by the healthcare organization) shall be up-graded to category 1;
A situation that on the basis of available objective evidence may directly lead to unacceptable risk of patient harm or does not meet minimum standards of care.
Minor A lapse of either discipline or control during
the implementation of system/procedural requirements, which does not indicate a system breakdown or raise doubt that products or services will meet requirements. Overall system requirement is defined, implemented and effective.
