The Joint Commission’s HAI-Focused NPSG

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The Joint Commission’s HAI-Focused NPSG

October 20, 2009

Kelly L. Podgorny, RN, MS, CPHQ

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Presentation Outline

I. The Joint Commission: Culture of Safety and High Reliability Organizations.

II. The Center for Transforming Healthcare.

III. Evidence-Based Requirements: The HAI-Focused NPSG & the Compendium.

IV. NPSG 07.04.01 Central Line-Associated Blood Stream Infections (CLABSI).

V. Survey Issues for NPSG 07.04.01 CLABSI.

VI. Summary

VII. Questions & Answers

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Culture of Safety and High Reliability Organizations (HRO)

The Joint Commission’s vision: 2009, 2010, and beyond:

– Goal to promote a “Culture of Safety” in accredited health care organizations (HCO)StandardsNational Patient Safety GoalsReporting of Sentinel EventsExpectation of Root Cause AnalysisCore measures

Nudging hospitals towards becoming a High Reliability Organization (HRO).

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Culture of Safety and High Reliability Organizations

Movement Towards a HRO

Definition of an HRO: An organization that has succeeded in avoiding catastrophes in an environment where normal accidents can be expected due to risk or complexity.

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5 Characteristics of HROPreoccupation with failureReluctance to simplify interpretation of

problemsSensitivity to operationsCommitment to resilienceDeference to expertise*Source: Agency for Healthcare Research and Quality. Transforming Hospitals into High Reliability Organizations.

Rockville. MD: AHRQ. Available online at: http://www.ahrq.gov/qual/hroadvice/hroadviceexecsum.htm

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Two organizational processes that impact HRO status & a culture of safety:

Medication management

Infection prevention & control

Center for Transforming HealthcareStandardsNational Patient Safety Goals (NPSG)Compendium

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“Target Zero”

Goal: Virtual elimination of sentinel events,

never events, & accidents

TIME

Occurrence

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“Target Zero”Goal: Virtual elimination

of sentinel events,never events, & accidents

TIME

Occurrence

Goal: Culture of SafetyAchieved

and Sustained

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Culture of Safety-Standard LD-03.01.01:

Leaders create and maintain a culture of safety and quality throughout the organization.

Standard LD: 03.02.01

The hospital uses data and information to guide decisions and to understand variation in the performance of processes supporting quality and safety.

Standard LD: 03.05.01

Leaders implement changes in existing processes to improve the performance of the organization.

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Evidence-Based Requirements

The Joint Commission is prepared to transform science into evidence-based requirements (i.e. standards and NPSG).

A culture of safety and high reliability organizations must rely on evidence-based requirements in healthcare.

The Joint Commission’s goal is to have the standards and National Patient Safety Goals (NPSG) evidence-based.

Standards and NPSG are to be value driven: Implementation with a reasonable expenditure of resources.

The HAI-focused NPSG are one example.

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The Joint Commission’s

Center for

Transforming Healthcare

(http://www.centerfortransforminghealthcare.org/about/about.aspx?)

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The Joint Commission’s HAI-Focused NPSG

andThe Compendium of Strategies to

Prevent Healthcare-Associated Infections in Acute Care Hospitals

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Development of the Compendium

The HAI*-Allied Task Force was initiated by:– Society of Healthcare Epidemiology in America (SHEA) – Infection Disease Society of America (IDSA)

Primary partners include:– American Professionals in Infection Control (APIC) – The American Hospital Association (AHA) – The Joint Commission

Work of the Task Force began in December 2006

Compendium was published in October 2008– Online: http://www.shea-online.org/about/compendium.cfm

Special edition in SHEA’s journal: Infection Control and

Epidemiology , Volume 29, Supplement 1

*Healthcare Associated Infections

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Components of the Compendium

The Compendium was developed for 6 common HAI including:

1. Clostridium difficile infections (CDI)

2. Methicillin-resistant S. aureus (MRSA)

3. Central line-associated bloodstream infections (CLABSI)

4. Catheter-associated urinary tract infections (CAUTI)

5. Surgical site infections (SSI)

6. Ventilator-associated pneumonia (VAP)

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What’s different about the Compendium?– The Compendium includes the first aggregation of evidence-

based recommendations for the 6 HAI with an implementation focus.

– Collaborative effort involving:Experts in infection prevention

and control: SHEA, IDSA, APICThe Joint CommissionAmerican Hospital Association (AHA)

– Endorsed and supported by a variety of organizations– Focuses on accountability

Compendium was published in October, 2008– Special edition in SHEA’s journal: Infection Control and

Epidemiology , Volume 29, Supplement 1– Online: http://www.shea-online.org/about/compendium.cfm

What’s different about the Compendium?

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The HAI-Focused NPSG

2009 HAI NPSG

NPSG.07.03.01: Implement evidence-based practices to prevent health care–associated infections due to multidrug-resistant organisms in acute care hospitals.

NPSG.07.04.01: Implement evidence-based guidelines to prevent central line–associated bloodstream infections.

NPSG.07.05.01: Implement best practices for preventing surgical site infections.

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Compendium and NPSG Comparison

Compendium Strategies 2009 HAI NPSG(Full implementation 1/1/2010)

1. Strategies to prevent Central line associated bloodstream infections

NPSG 07.04.01 Implement evidence-based guidelines to prevent central line–associated bloodstream infections.

2. Strategies to prevent Ventilator associated pneumonia

No

3. Strategies to prevent Catheter-associated urinary tract infections

No

4. Strategies to prevent Surgical site infections

NPSG 07.05.01 Implement best practices for preventing surgical site infections.

5. Strategies to prevent Methicillin-resistant S. aureus

NPSG 07.03.01 Implement evidence-based practices to prevent health care–associated infections due to multidrug-resistant organisms in acute care hospitals.

6. Strategies to prevent Clostridium difficile infections

NPSG 07.03.01 Implement evidence-based practices to prevent health care–associated infections due to multidrug-resistant organisms in acute care hospitals.

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2009 NPSG 07.04.01

Central Line-Associated

Blood Stream Infections (CLABSI)

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2009 NPSG 07.04.01: Prevent Central Line–Associated Bloodstream Infections

Key Points for NPSG 07.04.01 (2009)

– Elements of performance (EP) 1 through 4 are the 2009 phase-in requirements with key milestones.

– EP 6 through 9 focus on organizational process requirements (i.e. education, reporting).

– EP 10 through 15 focus on central line insertion requirements.

– EP 16 and 17 focus on post insertion care.

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NPSG.07.04.01 Implement evidence-based practices to prevent central line–associated bloodstream infections.

Elements of Performance for NPSG.07.04.01

1. As of April 1, 2009, the hospital’s leadership has assigned responsibility for oversight and coordination of the development, testing, and implementation of NPSG 07.04.01.

2. As of July 1, 2009, an implementation work plan is in place that identifies adequate resources, assigned accountabilities, and a time line for full implementation of NPSG 07.04.01 by January 1, 2010.

3. As of October 1, 2009, pilot testing in at least one clinical unit is under way for the requirements in NPSG 07.04.01.

4. As of January 1, 2010, the elements of performance in NPSG 07.04.01 are fully implemented across the organization.

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5. As of January 1, 2010, the hospital educates health care workers who are involved in these procedures about health care-associated infections, central line–associated bloodstream infections and the importance of prevention. Education occurs upon hire, annually thereafter, and when involvement in these procedures is added to an individual’s job responsibilities.

6. As of January 1, 2010, prior to insertion of a central venous catheter, the hospital educates patients and, as needed, their families about central line–associated bloodstream infection prevention.

7. As of January 1, 2010, the hospital implements policies and practices aimed at reducing the risk of central line–associated bloodstream infections that meet regulatory requirements and are aligned with evidence-based standards (for example, the Centers for Disease Control and Prevention (CDC) and/or professional organization guidelines).

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8. As of January 1, 2010,the hospital conducts periodic risk assessments for central line–associated bloodstream infections, measures central line–associated bloodstream infections rates, monitors compliance with evidence-based practices, and evaluates the effectiveness of prevention efforts.

9. As of January 1, 2010, the hospital provides central line–associated bloodstream infection rate data and prevention outcome measures to key stakeholders, including leaders, licensed independent practitioners, nursing staff, and other clinicians.

10. As of January 1, 2010, use a catheter checklist and a standardized protocol for central venous catheter insertion.

11. As of January 1, 2010, perform hand hygiene prior to catheter insertion or manipulation.

12. As of January 1, 2010, for adult patients, do not insert catheters into the femoral vein unless other sites are unavailable.

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13. As of January 1, 2010, use a standardized supply cart or kit that is all inclusive for the insertion of central venous catheters.

14. As of January 1, 2010, use a standardized protocol for maximum sterile barrier precautions during central venous catheter insertion.

15. As of January 1, 2010, use a chlorhexidine-based antiseptic for skin preparation during central venous catheter insertion in patients over 2 months of age, unless contraindicated.

16. As of January 1, 2010, use a standardized protocol to disinfect catheter hubs and injection ports before accessing the ports. 17. As of January 1, 2010, evaluate all central venous catheters routinely

and remove nonessential catheters.

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Using the HAI NPSG & Compendium Together

The HAI NPSG were based on the implementation strategies described in the Compendium.

The Compendium provides additional clinical detail to the requirements in the NPSG.

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Relationship of NPSG to the Compendium

NPSG 07.04.01

NPSG.07.04.01: Implement evidence-based guidelines to prevent central line–associated bloodstream infections.

EP 14. As of January 1, 2010, use a standardized protocol for maximum sterile barrier precautions during central venous catheter insertion.

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Relationship of NPSG to the Compendium

Compendium-CLABSI

B. At insertion 5. Use maximal sterile barrier precautions during

CVC insertion (A‐I).a. Use maximal sterile barrier precautions.

i. A mask, cap, sterile gown, and sterile gloves are to be worn by all healthcare personnel involved in the catheter insertion procedure.

ii. The patient is to be covered with a large sterile drape during catheter insertion.

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Survey Issues

For NPSG

07.04.01-CLABSI

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Survey Issues

Surveyors will survey the HAI-Focused NPSG not the Compendium.

Surveyors will use the Compendium as an educational resource through the remainder of 2009, 2010 and beyond.

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Frequently asked Question (FAQ) On NPSG 07.04.01 CLABSI

Whole-house surveillanceQ. Must we perform surveillance on all central lines, or is targeted

surveillance okay?A. Infection surveillance must be performed on all central lines; these lines

carry significant risk of morbidity and mortality regardless of circumstances. Limiting surveillance to certain types of lines, patient care units or service lines is not allowable under NPSG.07.04.01.

DocumentationQ. Please explain the documentation icons for EPs 10 and 16. What

will surveyors expect to see?A. EP 10 requires use of “a catheter checklist and a standardized protocol for

central venous catheter insertion” The checklist or protocol is not required to be a part of the patient’s medical record. A simple indication that the checklist or protocol was completed, perhaps via a checkbox or brief note, is sufficient.EP 16 requires use of a “standardized protocol to disinfect catheter hubs and injection ports before accessing the ports”. This is not a patient-specific documentation requirement. Surveyors will ask to see each organization’s protocol; this may be in the form of a policy, protocol, etc

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Summary

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Education on the HAI-Focused NPSG

An HAI-focused NPSG has been developed by The Joint Commission and Joint Commission Resources for accredited and certified organizations

Title: HAI: From the Bedside to C-Suite

Focus is on achieving compliance with the HAI-focused NPSG

Features Louise Kuhny and Barb Soule

Available at: http://www.jointcommissionconnect.org/

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Key Points

– The Joint Commission’s focus: High reliability organizations and a “culture of safety” are required to sustain the elimination of HAI.

– The Joint Commission is prepared to transform science into value driven requirements and has successfully done so with the HAI-focused NPSG.

– The Joint Commission recently launched The Center for Transforming Healthcare.

– The Compendium includes the first aggregation of evidence-based recommendations for the 6 HAI in an implementation format.

– The Joint Commission’s HAI-focused NPSG and the Compendium can be used together as a strategy for reducing HAI in your organization.

– The Joint Commission and Joint Commission Resources recently developed a webinar focusing on the HAI NPSG.

Summary

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Summary

Compendium

Web address:

http://www.shea-online.org/about/compendium.cfm

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Summary

The Joint Commission

Contact Information:

Kelly L. Podgorny RN, MS, CPHQ

Project Director

Division of Standards and Survey Methods

The Joint Commission

Telephone: 630-792-5108

E-mail: [email protected]

Documents

The Joint Commission’s HAI-Focused NPSG