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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
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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.
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Our Organizing Principle
Leading the Way to Zero
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Imagine a Day of Zero
Zero complications of careZero missed opportunitiesZero overuseZero harmZero lost revenueZero harm events of any kind
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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
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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
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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
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IC Risk AssessmentFactors to Include
Geographic locationEnvironment concernsPopulation servedArea endemic concernsCare, treatment and services providedRegulatory/state specific requirements
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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
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Assign Values Based on Risk
Score each itemRank order using risk scaleEach organization’s priorities will be
different
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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)
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16Infection Control Risk Assessment, APIC
APIC Infection Control Risk Assessment Tool Health Center Examples
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17Infection Control Risk Assessment, APIC
APIC Infection Control Risk Assessment Tool Health Center Examples
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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)
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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
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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)
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Risk Assessment and Plan Done with Interdisciplinary Input
Medical providersDental providersAdministratorsNursingStaff from sterilization/HLD departmentLeadersEmployee healthOthers
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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
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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%
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Health Center Infection Control
Tool/Checklist
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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
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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
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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/
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Health CenterInfection Control (IC)
PurposeBackground InformationIC Risk AssessmentIC PlanTargeted health center IC toolQ&A
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Questions?