National Safety and Quality Health Service Standards

1. National Safety and Quality Health Service Standards Standard 3 – Preventing and Controlling HAIs Sue Greig Senior Project Officer, ACSQHC

2. The NSQHS Standards Standard 2 Partnering with Consumers Standard 1 Governance for Safety and Quality in Health Service Organisations Standard 3 Healthcare Associated Infections Standard 10 Preventing Falls and Harm from Falls Standard 4 Medication Safety Standard 9 Recognising and Responding to Clinical Deterioration in Acute Health Care Standard 5 Patient Identification and Procedure Matching Standard 8 Preventing and Managing Pressure Injuries Standard 7 Blood and Blood Products Standard 6 Clinical Handover

3. National Safety and Quality Standards • Approved by health ministers September 2011 • Address areas where: • Large numbers of patients effected • Known gap between current situation and best practice outcomes • Evidence based, achievable improvement strategies exist

4. Key points • Standards are about safe patient care • Safety and quality is an organisational responsibility • Communicate and plan together • Gap analysis and risk assessment • Prioritising – decision grid

5. A patient’s perspective of health care … I have a right to safe and high quality care. This means: • To be free of being infected by my hospital or health worker • To be given the right medications at the right time • To be assessed for the risk of VTE • To have the correct procedure, operation, test, x-ray • To be rescued if my condition unexpectedly deteriorates

6. The quality and safety problem • The gap between the delivery of recommended care and the care that is actually provided can be as high as 50%.

7. Why ? • Is it … • Ignorance • Lack of training • The lack of applied ‘common sense’ • Mobility of HCWs • Inconsistent curriculums and assessment of competence • Inconsistent practices and resources • Lack of access to evidence based information • Care is too complex • Patients are too complex • We are too busy • Not enough staff • Clinicians don’t care

8. Is it all just too hard????

9. Standard 3 – Preventing and Controlling Healthcare Associated Infections • Applied in conjunction with • Standard 1, ‘Governance for Safety and Quality in Health Service Organisations’ • Standard 2, ‘Partnering with Consumers’ • Standard 4, ‘Medication Safety’ • Standard 6, ‘Clinical Handover’

10. Why have a Standard about preventing infection? • preventable • common • increase morbidity, mortality, pain & suffering • cost to patients, hospital staff, health system • no single solution • range of strategies

11. Criteria for Standard 3 • Governance and systems for IPC and surveillance • Strategies for IPC • Managing patients with infections or colonisation • AMS • Cleaning, disinfection or sterilisation • Communicating with patients and carers

12. Benefits of Standard 3 • Reduce risk of patient harm and death • Clarifies roles, responsibilities and accountabilities • Improves information • Antimicrobial stewardship • Improves organisational governance • Tracking of invasive, reusable devices • Increases focus on specific evidence based strategies

13. Priorities for Standard 3 Effective governance Identifying what is working well Knowing your risks and/or gaps Having systems to gather, review and report evidence Having a plan to address risks and respond Aim for the best (either 0 or 100%) Ability to demonstrate progress/improvement Engage with others in the organisation

14. What is different? • Responsibility of governance and management systems • Making a difference to patient safety • Managing risk • Evidence of process, systems and outcomes • Recognition of the consumer as a partner

15. Top tips for responding to Standard 3 • Assess the current situation • Risk assessment • Current governance arrangements • Current policies, processes and resources • Data currently collected • Any audit results • Current resistance patterns, infections • Raise awareness • Share results, ask for interested people to be involved

16. How have organisations performed so far? • 737 organisations assessed against Std 3 - organisational wide (275), mid-cycle (445) and interim assessments (17) • 1352 public, private and day procedure services eligible to be assessed in Australia • In 2013, of the 1352 eligible services >50% have been surveyed and have met Standard 3 requirements

17. How have organisations performed so far? In 2013: • 55% were private organisations • 45% were public organisations • 60% of public organisations met all core actions at initial assessment • 55% of private organisations met all core actions at initial assessment • 90% of organisational wide surveys had core and developmental actions to be addressed within 120days • 32% of organisational wide surveys had core only actions to be addressed within 120days

18. Where to from here • Review of the current Standards by 2017 • Ongoing accreditation of health service organisations • Review of the accrediting agencies accreditation scheme • Improve on inter-ratter reliability • Further review of the data received on the first 12 months • Ongoing support for organisations and agencies with development of resources to assist with responding to the Standards

19. Criteria for Standard 3 • Governance and systems for IPC and surveillance • Strategies for IPC • Managing patients with infections or colonisation • AMS • Cleaning, disinfection or sterilisation • Communicating with patients and carers

20. Cleaning, disinfection and sterilisation Links between Standard 1 and Standard 3 as well as within Standard 3 with criteria – Governance and Cleaning, Disinfection and Sterilisation • 3.15 – Environmental cleaning • 3.16 – Reprocessing reusable medical equipment, instruments and devices • 3.17 – Identification of patients on whom reusable medical devices have been used (traceability) • 3.18 – Competency based training for those who are involved in decontamination of reusable medical devices

21. How times have changed…. 1941 – “Husbands are like Kleenex – soft, strong and dependable” Ball of Fire 1985 – “Husbands are like Kleenex – soft, strong and disposable” Clue Sterilising services are an area that has experienced change in the last 30 years both with technology and scope of services.

22. “I am a pushover for Streptococcus”Sugarpuss O’Shea (Barbara Stanwick), Ball of Fire, 1941 3.16.1 - Reprocessing reusable medical equipment, instruments and devices in accord with relevant national or international standards and manufacturer instructions. Why? • Minimise risks of infection to patients and the workforce How? • Governance - 3.1.1 organisational risk assessment and policy, procedures and/or protocols

23. 3.16.1 When looking at risk consider: What reprocessing the organisation needs to consider based on services provided Are there policies, procedures and protocols to cover the scope of services provided How will the organisation achieve this – equipment and consumables Outsourcing to external providers Single use items Purchase of sterile stock Providing reprocessing services to other organisations/individuals

24. What other evidence supports 3.16.1 • Product selection • Equipment and environmental maintenancethat includes schedules, fault and variance reporting • Quality control systems that include document control, audit and compliance reports • Incident reports • Education or training for the introduction of new products and equipment

25. “Tag ‘em and bag ‘em” Platoon 1986 3.17.1 - Identification of patients on whom reusable medical devices have been used (traceability) Why? • Minimise risk to patients of contracting infection from reusable medical devices How? • Look at what current systems are and can they be improved?

26. “Dobby didn’t mean to kill – Only maim and seriously injure” Harry Potter and the Deathly Hallows, 2011 – Dobby the house elf What are the risks relating to traceability? • Can the organisation identify reusable medical devices? • Can the organisation identify on which patient these items were used? • Can the organisation do this retrospectively?

27. “ Practice makes perfect” Clue 1985 3.18.1 - Competency based training for those who are involved in decontamination of reusable medical devices. Why? • Appropriate and correct decontamination is critical to reprocessing of reusable medical devices to reduce risk of infection How? • Provision of appropriate training to those who undertake decontamination and assessing competence of the relevant workforce.

28. “What we’ve got here is a failure to communicate” Cool Hand Luke, 1967– Paul Newman What are some of the risks to consider: • Look at where decontamination occurs and who undertakes the task? • Have they been trained? • How and by what method? • Is the training current and in line with best practice? • Is the training consistent? • Do they have the resources to safely undertake decontamination? • Is competency assessed and if so – by whom/how?

29. “The subconscious does not make mistakes” Ball of Fire, 1941- Gary Cooper, Barbara Stanwick The key points for an organization to consider for cleaning, disinfection and sterilization of reusable medical devices are: • Risk assess the scope of services in the organisation • Engage with governance to respond to identified risks • Have policies, procedures and protocols to cover the scope of services • Have a system to identify patients on whom reusable medical devices have been used (traceability) • Identify and then provide or access competency based training for those who are involved in decontamination of reusable medical devices.

30. Last ‘classic’ quote…… Let whoever is in charge keep this simple question in her head – not how can I always do this thing right myself, but how can I provide for this right thing to be always done? Florence Nightingale

31. For further assistance……. Advice Centre 1800 304 056 accreditation@safetyandquality.gov.au Service will consist of: • Dedicated telephone line operated during business hours • Dedicated email address for queries • Website with frequently asked questions generated from phone and email queries