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INFECTION CONTROL PLAN-‐ MAINTAINING COMPLIANCE WITH THE INFECTION CONTROL AND PREVENTION

STANDARDS AND REGULATIONS: CMS CfC 416.51

Lee Anne Blackwell, RN, BSN, EMBA, CNOR Vice President Clinical Services

Practice Partners in Healthcare, Inc.

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MAINTAINING COMPLIANCE

WITH IC PLAN

OBJECTIVES 1.Describe components of an InfecIon Control (IC) Plan.

2. Examine internal and external reporIng requirements for the ambulatory surgery center related to your IC plan

3. Discuss responsibiliIes of an IC Nurse PrevenIonist (ICP).

4. IdenIfy top infecIon control focus areas during regulatory and accreditaIon surveys. 5. Implement ONE new idea and acIon to support your

center’s InfecIon Control Plan!

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CMS CfC 416.51: Infec'on Control in 2 standards:

•  Sanitary environment (416.51 a) •  Infec'on control program (416.51 b)-‐ “The infec2on control and preven2on program must include documenta2on

that the ASC has considered, selected, and implemented na2onally recognized infec2on control guidelines.” and… The IC program must be “under the direc2on of a designated and qualified professional who has training in infec2on control”

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OBJECTIVE ONE:

Describe Components of an Infec'on Control (IC) Plan

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The IC Plan must contain the following: 1.  A purpose statement idenIfying plan based on guidelines from

leading authoriIes in IC 2.  IdenIficaIon of IC Plan role, responsibility, support, and

oversight by organizaIon management, GB (& MEC) 3.  An authority statement – who is “in charge” of the IC Plan 4.  Plan goals 5.  Plan scope 6.  InvesIgaIon and surveillance processes 7.  IdenIfied risks and risk assessment processes 8.  IdenIfied strategies to miIgate risks 9.  EducaIon plan for ICP and staff (including MED /AHP staff) 10. ReporIng processes

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MAINTAINING COMPLIANCE 1. A purpose statement iden'fying plan based on guidelines and best recommended prac'ces from leading authori'es in IC:

•  Centers for Disease Control and PrevenIon (CDC) •  Assoc for Professionals in InfecIon Control and Epidemiology (APIC) •  Society for Healthcare Epidemiology of America (SHEA) •  AssociaIon of PeriOperaIve Registered Nurses (AORN) •  Society of Gastroenterology Nurses and Associates, Inc. (SGNA) •  OccupaIonal Safety and Health AdministraIon (OSHA) •  NaIonal InsItute for OccupaIonal Safety and Health (NIOSH) •  American InsItute of Architects (AIA) •  Assoc for the Advancement of Medical InstrumentaIon (AAMI) •  InternaIonal Assoc of Healthcare Central Service Materiel

Management (IAHCSMM) •  AccreditaIon Agencies (TJC, AAAHC, AAAAF, etc.)

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2. The IC Plan must iden'fy the organiza'on’s role, responsibility, support, and oversight by management, GB/MEC.

•  The IC plan must be developed by center Leadership and clinical IC designee

•  The InfecIon Control Plan must be approved by MEC/GB

•  Leadership must be commiked and supporIve

•  Leadership must acIvely parIcipate in all efforts to control infecIon

•  Leadership must support IC best pracIces, idenIficaIon of expert resources, and encourage conInuous improvement according to the foundaIon of the PI program

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MAINTAINING COMPLIANCE 3. The IC Plan must include an AUTHORITY statement

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(FACILITY NAME)

Infection Control Professional Competency and Authority Statement

The infection control professional will be responsible to demonstrate competency through interest in the field, formal and informal training, and through appropriate experience required for the position as described in the job description. The infection control professional will be responsible to abide by the Infection Control Policies and Procedures and related infection control competencies of (FACILITY NAME).

____________________________________________

AUTHORITY STATEMENT –NAME OF INFECTION CONTROL NURSE

For:

(FACILITY NAME)

The Governing Body of (FACILITY NAME) and the Medical Director hereby delegates authority to the infection control professional to act on all matters regarding infection control; to carry out the functions of the Infection Control Program, and institute any appropriate control measures or studies when there is reasonably considerable danger to any patient or persons. _________________________________ ____________________ Chair, Medical Executive Committee/ Date Medical Director/Chief of Medical Staff _________________________________ _____________________ Administrator / Nurse Manager Date


4. The IC Plan must have iden'fied goals that:

•  Flow from overall philosophy, mission and vision of organizaIon

•  Allow flexibility– room to alter plan in response to unexpected disease processes or environmental issues

•  Support IC Plan review regularly, at least annually, for necessary changes

•  Support the IC Plan to be communicated to everyone in the organizaIon responsible to parIcipate in the plan

•  Focus on strategies for reducing infecIon risks

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MAINTAINING COMPLIANCE 5. The IC Plan must have a defined SCOPE (the “who”, the “what”, and the “how”) that:

•  WHO: IdenIfies populaIon to be served •  WHO: IdenIfies all healthcare workers who will parIcipate in the ASC’s IC Plan

•  WHAT: IdenIfies what indicators or metrics will be measured to idenIfy paIent safety opportuniIes for improvement-‐ QAPI; (hand hygiene compliance, ABX admin Iming, Influenza vaccine rates, surgical preps, sterilizaIon processes, terminal cleaning, management of surgical apre, etc.)

•  HOW: IdenIfies how the infecIon control service will be implemented for paIents, staff, environment

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MAINTAINING COMPLIANCE 6. Inves'ga'on and Surveillance Processes:

•  Ensure a consistent process to retrieve infecIon informaIon: –  Physician lekers –  Verbal communicaIon with physicians –  PaIent care follow-‐up assessments

•  IniIate consistent infecIon surveillance processes: –  PaIent outcomes -‐ the value of any plan lies in the data collected regarding paIent outcomes

–  InfecIon data must be accurately collected – Methods of surveillance for infecIons and anImicrobial resistant pathogens

–  Trending log 11

MAINTAINING COMPLIANCE 7. The IC Plan must address risks and risk assessment measures.

•  InfecIon Control Risk Assessments (ICRA); idenIfying risks for acquiring and transmipng infecIons –  PopulaIon served –  Facility locaIon –  Community

•  ICRA idenIfies external factors: –  Community disease and infecIon prevalence –  Community risks (conduct risk assessments)

•  ICRA IdenIfies internal factors: –  Internal disease and infecIon prevalence –  Internal risks (conduct risk assessments)

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7. The IC Plan must address risks and risk assessment measures (con'nued)

Ques'ons to consider for IC risk assessment: •  What type of paIents do we serve? •  What are the most common diagnoses and paIent co-‐morbidiIes? •  What are most frequently performed surgical or invasive

procedures? •  What type of paIents increase liability and/or costs for the center? •  What type of health concerns exist in the community? •  Which paIents are at increased risk for infecIon?

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7. The IC Plan must address risks and risk assessment measures (con(nued)

•  Once risks are idenIfied: –  PrioriIze idenIfied risks –  Establish GOALS and OBJECTIVES for risk prevenIon, miIgaIon –  IdenIfy strategies to miIgate risks –  Target resources to help with risk miIgaIon strategies

•  Agencies: CDC, OSHA, etc. •  Professional organizaIons: APIC, AORN, AAMI, IAHCSMM, etc.

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8. Iden'fied Strategies to Mi'gate Risks: •  Review paIent processes of care and paIent outcomes to idenIfy best pracIce strategies for prevenIon and control

•  Implement processes to support internal and external infecIon outbreak control

•  Implement appropriate precauIons: –  Standard PrecauIons –  Transmission-‐based precauIons –  Blood-‐borne precauIons

•  Implement Hand Hygiene program with monitoring •  Implement educaIon plan

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8. Iden'fied Strategies to Mi'gate Risks (con'nued): The IC Plan must address •  CollaboraIon with Environment of Care-‐Safety Coordinator (OSHA training, sharps safety, employee safety risk assessments)

•  CollaboraIon with Employee Health Nurse (Bloodborne Pathogens training, vaccinaIon program, employee health awareness program)

•  State, Federal, AccreditaIon Standards and Guidelines

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8. Iden'fied Strategies to Mi'gate Risks (con'nued): The IC Plan must address policies and procedures for •  Employee health and safety •  Workplace safety •  educaIon & training, for employees, contractors, medical staff & AHP, and paIents

•  PaIent screening, tesIng •  Standard PrecauIons/Transmission-‐Based PrecauIons •  AsepIc, sterile technique in all areas •  Cleaning, disinfecIon, high-‐level disinfecIon, sterilizaIon •  Environmental safety and condiIons, traffic pakerns

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MAINTAINING COMPLIANCE 9. Educa'on Plan for Employees, Medical Staff, Contractors, Vendors, Guests, Pa'ents:

•  ASC InfecIon Control Plan and program •  Hand Hygiene •  Instrument and equipment processing personnel –SterilizaIon

and High-‐Level DisinfecIon (CerIficaIon gaining momentum and recogniIon)

•  InfecIous Waste Management – communicaIon and educaIon of appropriate disposal techniques

•  Personal ProtecIve Equipment •  Sharps Safety and Bloodborne Pathogens •  Standard PrecauIons/Transmission-‐based PrecauIons •  MedicaIon InfecIon Control Safety PracIces •  Sanitary Environment

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9. IC NURSE SHOULD MAINTAIN DOCUMENTATION OF TRAINING (Example of Training LOG)

(FACILITY NAME) Infection Control Coordinator TRAINING RECORD

Infection Control Nurse: _______________________________________________ YEAR: ______________

PROGRAM NAME DATE


OBJECTIVE TWO: Examine internal and external repor'ng

requirements for the ambulatory surgery center related to your IC plan (THE 10TH ELEMENT of the IC Plan)

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10. Repor'ng Processes:

•  InfecIon data must be accurately reported

•  CommunicaIng reportable diseases to public health authoriIes (ENSURE POLICY IN PLACE!)

•  CommunicaIng reportable diseases and events to ASC quality commikee, medical leadership

•  RecommendaIons and acIons based on infecIon prevenIon and control best pracIces related to outcomes and trends

•  Mandatory reporIng requirements – NHSN!

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MAINTAINING COMPLIANCE 10. Repor'ng Processes: MANDATORY -‐ NHSN!

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MAINTAINING COMPLIANCE 10. Repor'ng Processes: MANDATORY-‐ NHSN!

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http://www.qualityreportingcenter.com/asc/asc-status-listing-lookup-tools/

MAINTAINING COMPLIANCE 10. Repor'ng Processes: MANDATORY-‐ NHSN!

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MAINTAINING COMPLIANCE 10. Repor'ng Processes: ASC 8-‐ Influenza Vaccina'on Coverage among HCP •  Intent: assess the percentage of HCP immunized for influenza during the flu season

•  Three categories of healthcare personnel will include: –  Employees on payroll –  Licensed independent pracIIoners-‐ medical staff, allied health staff affiliated, credenIaled

–  Student/trainee and volunteers who do not get a paycheck •  Data collecIon begins with immunizaIons for flu season 10/1/2014 through 03/31/2015

•  Deadline for data reporIng extended for 2014-‐2015 flu season from 03/15 to 08/15 and to 9/30/2015

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10. Repor'ng Processes: Infec'on Control CLAIMS-‐BASED and WEB-‐BASED MEASURES

•  InfecIon Control CLAIMS-‐based process measure to Ambulatory Surgery Center Quality ReporIng (ASCQR); “Q-‐NET” (for CY 2014 payment determina2on:

ASC – 5: Prophylac2c ABX 2ming •  InfecIon Control WEB-‐based process measure to NHSN for

CY 2016 payment determina2on: ASC – 8: Influenza vaccina2on coverage among

healthcare personnel (HCP)-‐ Due 9/30/2015 •  For more informaIon on measures reporIng, go to

www.qualityreporIngcenter.com; and hkp://www.cdc.gov/nhsn/ambulatory-‐surgery/index.html

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MAINTAINING COMPLIANCE WITH INFECTION CONTROL

AND PREVENTION STANDARDS OBJECTIVE THREE:

Discuss Responsibili'es of the Infec'on Control Nurse Preven'onist

(ICNP or ICP)

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MAINTAINING COMPLIANCE The ICP •  Is approved by the Governing Body (GB)

–  DocumentaIon in ICP organizaIon employee file

•  Maintains documentaIon of job descripIon, competencies •  Is responsible for the facility IC Plan •  Provides educaIon and training on IC plan, goals and objecIves to staff

•  Maintains documentaIon of training, educaIon and knowledge in infecIon control

•  Seeks guidance from leading authoriIes in IC for ongoing educaIon, training, IC Plan management including updates

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APIC: www.apic.org AORN: www.aorn.org CDC: www.cdc.gov OSHA: www.osha.gov NIOSH: www.niosh.gov SHEA: www.shea-‐online.org AAAHC: hkp://www.aaahc.org/en/educaIon/Webinars/

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SGNA: www.sgna.org IAHCSMM: www.iahcsmm.com AAMI: www.aami.org AIA: www.aia.org The Joint Commission: www.jointcommission.org

The ICP connects with IC educa'onal resources to maintain current knowledge and trends, from leading authori'es such as:

There are PLENTY MORE of web-based resources available to the ICP!

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MAINTAINING COMPLIANCE 10. EDUCATION RESOURCES:

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Becker’s Hospital Review- Original Producer/publisher of this content; http://www.beckershospitalreview.com/quality/endoscopes-and-mdros-how-to-avoid-an-outbreak.html


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http://solutions.3m.com/wps/portal/3M/en_US/IPD-NA/3M-Infection-Prevention/Education/


•  InfecIon Control TODAY web-‐publicaIon: hkp://www.infecIoncontroltoday.com/

•  Medline University: https://www.medlineuniversity.com/

•  Olympus University: http://issuu.com/olympusamerica/docs/olympus_university_brochure?e=0

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MAINTAINING COMPLIANCE The ICP •  Conducts an ongoing & annual evaluaIon of the IC Plan

•  Encourages and directs collaboraIon of medical staff and employees regarding IC Plan acIviIes

•  Conducts process of care and outcomes audits via MD lekers and paIent postop call communicaIon

•  Performs risk assessments

•  Completes invesIgaIons of reported infecIons

•  Reports plan and findings to facility medical leadership 33

MAINTAINING COMPLIANCE IC plan surveillance process-‐IC Repor'ng sequence example: 1.  InfecIon Report 2.  InfecIon Log 3.  Trending Report, monthly, quarterly, annual 4.  SterilizaIon and HIGH Level DisinfecIon Compliance Report 5.  IC Employee Exposure Risk Assessment 6.  InfecIon Risk Assessment 7.  ReporIng of Communicable Diseases to IdenIfied Health

Authority 8.  IC Monthly Audit (Grand Rounds) 9.  IC compliance monitoring reports-‐Hand Hygiene, PI projects 10.  Updates and changes to your IC Plan, including annual

reviews.

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MAINTAINING COMPLIANCE IC plan inves'ga'on and surveillance process-‐steps

when infec'ons are iden'fied:

1.   Complete Infec'on Report: a.  Review medical record b.  Explore processes of care

1.  PaIent assessment 2.  H &P 3.  SterilizaIon and high-‐level disinfecIon records 4.  Get culture report if at all possible!

2.   Assess for Trends: staff, room, procedure type, MD 3.   Report findings to management, QC, MEC/GB for

ac'ons

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AND PREVENTION STANDARDS OBJECTIVE FOUR:

Iden'fy Top Infec'on Control Focus Areas During

Regulatory and Accredita'on Surveys

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•  HISTORY: Beginning 2009-‐accrediIng bodies revised their guidelines to include the new CMS (Center for Medicare and Medicaid Services) CondiIons for Coverage. Both TJC and AAAHC completed pilots in ASC’s to include CfC’s and expanded the infecIon control assessment using the CMS InfecIon Control Worksheet in the survey process.

•  The CMS IC Worksheet is periodically updated and consistently used for accreditaIon/regulatory surveys.; last updated June 2015

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MAINTAINING COMPLIANCE INFECTION CONTROL SURVEYOR WORKSHEET 2015

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CMS IC Worksheet 2015: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-15-43.pdf Also see on ASCA website to download the current worksheet at: http://www.ascassociation.org/viewdocument/?DocumentKey=ae5c22ac-c283-4a36-b548-06ce81f200a0


Top Infec'on Control Focus Areas:

1.   Hand Hygiene / Personal Protec've Equipment (PPE)

2.   Safe Injec'on prac'ces

5.   (A.) Single-‐Use Devices, (B.) Steriliza'on, and (C.) High Level Disinfec'on

6.   Environmental Cleaning –Sanitary Workplace

9.   Point of Care Devices HINT! This is STRAIGHT OFF THE CMS IC WORKSHEET!

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MAINTAINING COMPLIANCE Surveyors will look at the types of IC training for the ICP Acceptable training topics include but are not limited to: 1.  Elements of the IC Plan 2.  Role of the ICP 3.  InfecIon Risk Factors (SSI, PaIent, Environment, HCW’s) 4.  Hand hygiene compliance 5.  ImplemenIng and maintaining a sanitary work

environment 6.  Best pracIces w/ sterilizaIon processes, including flashing 7.  Cleaning and disinfecIon 8.  AsepIc technique best pracIces 9.  Employee Health 10.  InfecIon Control PaIent Screening and Assessment

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OBJECTIVE FIVE:

Implement at least ONE new idea and ac'on to support your center’s

Infec'on Control Plan and Survey Readiness!

MAINTAINING COMPLIANCE Ac(on Items!

1.  Review and communicate your IC plan, policies

2.  Ensure your facility ICP has an authority statement, JD, and documented competencies in place

3.  Implement clear and systemized invesIgaIon and surveillance processes

4.  Complete your IC risk assessments and reports

5.  IdenIfy & implement strategies to miIgate infecIon risks

6.  Report your IC plan acIviIes to your QC/MEC/GB

7.  Educate your team members, medical staff, vendors

8.  Develop, manage and direct IC policies and procedures

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MAINTAINING COMPLIANCE-‐ RESOURCES

•  CMS ASC Quality ReporIng Program Quality Measures SpecificaIons Manual, available at www.qualitynet.org

•  Quality ReporIng center at www.qualityreporIngcenter.com

•  Ambulatory Surgical Center Quality Repor2ng Program Quality Measures Specifica2ons Manual 5.0 for measure informaIon & specificaIons for Medicare's ASC Quality ReporIng Program: hkp://qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1228772475754

•  ASCs can contact the ASCQR Program Support Contractor (SC) with quesIons regarding data or for technical support. Contact the ASCQR Program SC by email at [email protected] or by telephone at 866.800.8756.

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MAINTAINING COMPLIANCE-‐ RESOURCES

•  CDC’s NaIonal Health and Safety Network (NHSN) website for 5 step enrollment:

www.cdc.gov/nhsn/ambulatory-‐surgery/enroll.html “NSHN facility administrator enrollment guide”

•  Need to complete the 5 step SET-‐UP hkp://www.cdc.gov/nhsn/ambulatory-‐surgery/setup.html BEFORE reporIng

•  ReporIng data to CDC’s NHSN requires user authorizaIon through Secure Access Management Services (SAMS) for access to NHSN: hkps://sams.cdc.gov

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AND PREVENTION STANDARDS

Lee Anne Blackwell, RN, VP Clinical Services PracIce Partners in Healthcare, Inc. [email protected]

1-‐205-‐824-‐6250, ext. 5005

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INFECTION CONTROL

IS EVERYONE’S

RESPONSIBILITY!

infection(control(plan-( … · infection control professional to act on all matters regarding...

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