“The Stony Brook Way is My Way”

Stony Brook Medicine: Response to Quality Assurance and Performance Improvement

What We Need to Know

New York State Department of HealthCenter for Medicaid Medicare Services

[CMS]

All Cause Corrective ActionStony Brook Medicine

Developed 6/10/2015 Reviewed 6/19/2015 cm

DOH/CMS Areas of Deficiency:

1. Allegations of Sexual, Physical, or Psychological Abuse

2. Infection Control Practices3. Intravenous Therapy and Blood Product

Administration4. HIPAA, as it relates to PHI Disclosure5. Code Cart Standardization

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1. Didactic education

2. Skills based training and Simulation

3. Attestation- confirmed completion

4. Validation- check performance

5. Outcomes- compliance

IMPLEMENTATION /COMMUNICATION STRATEGY

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• DOH for CMS Allegation survey 4/28/15 – 5/4/15

• Finding related to process for investigation of patient complaints of Abuse & Neglect by a Staff member

• Actions: New Policy RI0057: Patient Allegations of Abuse/Neglect by a Staff

Member implemented prior to DOH exit Education to front line, managers, supervisors, directors & medical

staff via PPs, LMS, and continuing through annual re-certifications and new employee orientation

Abuse Complaint checklist to document actions

Policy: RI:0057 https://policymanager.uhmc.sunysb.edu/dotNet/documents/?docid=6063&mode=view

CMS ALLEGATION SURVEY

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• CMS document received evening of 6/3/2015 (on day 3 of TJC Survey)

• Follow up actions and clarification statements to be submitted by 6/15/2015

• Requires 100% education : Medical Staff must complete to 100% by 6/15/2015

• Requires 100% monitoring of responses to Abuse & Neglect complaints (13 to date since DOH visit)

• Requires feedback to Departments on Abuse & Neglect complaints

• Requires tracking & trending by department and individual

CMS REPORT 5/13/2015

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“The Stony Brook Way is My Way”

Administrative Policy on Isolation Precautions IC 0006

As soon as patients are identified as needing isolation:• Yellow card / chart, dedicated stethoscope / thermometer

• All rooms must have a Personal Protection Equipment [PPE] cabinet

in or in close proximity to the entryway• Cabinets must be stocked with gowns, gloves, surgical masks,

goggles and / or face shields• All HCWs are responsible for following the isolation precautions

delineated in the Hospital Policy and reminding other HCWs to do the same

• Families must be educated re: Hand hygiene practices and Patient’s isolation

HEALTHCARE EPIDEMIOLOGY DEPARTMENT

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All patients, regardless of status:• inpatient• outpatient• observation

Must be placed on the correct isolation precautions based upon the patient’s:

• personal history• clinical presentation• isolation code on Banner Bar

HEALTHCARE EPIDEMIOLOGY DEPARTMENT

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Administrative Policy on Hand Hygiene IC 0003

Hand Hygiene is performed:• Upon entering & exiting patient rooms• Before and after any contact with patient / environment,

regardless of +/- isolation status• In between dirty and clean procedures• Between separate portions of the physical exam re: clean vs dirty• OK to foam when entering a C diff room, but must wash hands

with SOAP / WATER upon exiting

Families must be educated on hand hygiene practices

DEPHEALTHCARE EPIDEMIOLOGY DEPARTMENT

ORMATICS

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Administrative Policy on Infection Control in patient transporting IC 0007

Patients on isolation must be transported using practices that minimize cross contamination

If patient is on isolation, the transporter must:• Perform hand hygiene, don correct PPE identified on the isolation yellow card before

entering room• Bring clean transfer equipment into the room, transfer patient to stretcher or wheelchair

as indicated• Cover patient with clean sheet• Remove isolation garb before exiting room, perform hand hygiene• When transferring patient on occupied bed, wipe the side rails and all accompanying

equipment with antimicrobial (purple) wipes, allowing for 2 minute dwell time prior to exiting the room

HEALTHCARE EPIDEMIOLOGY DEPARTMENT

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Administrative Policy on Infection Control in Patient Transporting IC 0007

• Patients on droplet and airborne precautions must themselves wear a well fitted surgical mask during transport prior to leaving the room to contain their secretions, thus preventing dissemination

• All other patients do not require a mask as the

mode/mechanism of transmission is not via droplet secretion

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Health Care Providers are NOT to carry multi-dose vials in pockets or case (pharmacy policy modified):

• From patient to patient• From room to room• When used on a patient with an infection, discard after use

Use single-dose containers whenever possible

When single-dose dispensers are not available:• Maintain aseptic technique• Perform hand hygiene• Prevent tip of dispenser from touching the patient• Wipe down container with antimicrobial (purple) wipes in between

every patient encounter and prior to returning it to the case.

HEALTHCARE EPIDEMIOLOGY DEPARTMENT

SBU Hospital Infection Control Policies • Hand Hygiene IC 0003• Multidrug Resistant Organisms (M-RO) IC 0010• Patient Care Equipment Cleaning IC 0013• Infection Control In Patient Transporting IC 0007• Isolation Precautions IC 0006• Prevention and Control of Clostridium defficile IC 0022• Prevention and Transmission of M. Tuberculosis

infection IC 0011• MM0012 Multiple Dose Vials, Multiple Use Containers• IC0012 Standard Precautions

Infection Control is in Your Hands

All consultants [MDs, NPs, PAs, etc] will notify primary nurse of their arrival prior to

entering patient room in ED and on the Units: “I’m here to see patient ____. Is there

anything I should know?”

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Audit and analysis of all IV and Blood Administration Policies

Development of educational materials aligned with best practices and SBUH policies

• Development of Skills Training stations• Development of Simulation scenarios• Training of Auditors• Systematic ongoing monitoring

IV THERAPY AND BLOOD ADMINISTRATION

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Removed complete patient name from slave monitors

• Rolling computer carts: instructing and auditing for open EMRs with PHI on the screen

• Education on the proper communication of PHI, with instruction for sensitivity to the environment and other people: only permitted use of incidental disclosure

HIPAA COMPLIANCE: PROTECTED HEALTHCARE INFORMATION

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All Pediatric and Adult Code Carts now include the appropriate Zoll Pads

Pediatric Code Cart now contains two sets of Zoll Pads: Children less than 8 years of age and over 8 years of age

All Code Carts now have consistent Code Cart checklists

CODE CART STANDARDIZATION

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Accountability• Attestation of all staff by 6/15/2015• Validation of training and education 6/15-6/20/2015• Remediation directives-as it occurs• Behavior-Based Expectations- continuous• Ongoing monitoring of outcomes• Patient Safety Rounding will include CMS Hospital Infection Control

Worksheet with relevant scoring.

ALL CAUSE CORRECTIVE ACTIONS

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