The Joint Commission’s HAI-Focused NPSG

1. The Joint Commission’s HAI-Focused NPSG October 20, 2009 Kelly L. Podgorny, RN, MS, CPHQ

2. Presentation Outline • The Joint Commission: Culture of Safety and High ReliabilityOrganizations. • The Center for Transforming Healthcare. • Evidence-Based Requirements: The HAI-Focused NPSG & the Compendium. • NPSG 07.04.01 Central Line-Associated Blood Stream Infections (CLABSI). • Survey Issues for NPSG 07.04.01 CLABSI. • Summary • Questions & Answers

3. 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) • Standards • National Patient Safety Goals • Reporting of Sentinel Events • Expectation of Root Cause Analysis • Core measures • Nudging hospitals towards becoming aHigh Reliability Organization (HRO).

4. 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.

5. Culture of Safety and High Reliability Organizations 5 Characteristics of HRO • Preoccupation with failure • Reluctance to simplify interpretation of problems • Sensitivity to operations • Commitment to resilience • Deference 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

6. Culture of Safety and High Reliability Organizations • Two organizational processes that impact HRO status & a culture of safety: • Medication management • Infection prevention & control • Center for Transforming Healthcare • Standards • National Patient Safety Goals (NPSG) • Compendium

7. Culture of Safety and High Reliability Organizations “Target Zero” Goal: Virtual elimination of sentinel events, never events, & accidents Occurrence TIME

8. Culture of Safety and High Reliability Organizations Goal: Virtual elimination of sentinel events, never events, & accidents “Target Zero” Occurrence Goal: Culture of Safety Achieved and Sustained TIME

9. Culture of Safety and High Reliability Organizations 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.

10. 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.

11. The Joint Commission’s Center for Transforming Healthcare (http://www.centerfortransforminghealthcare.org/about/about.aspx?)

14. The Joint Commission’s HAI-Focused NPSG and The Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals

15. 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

16. Components of the Compendium • The Compendium was developed for 6 common HAI including: • Clostridium difficile infections (CDI) • Methicillin-resistant S. aureus (MRSA) • Central line-associated bloodstream infections(CLABSI) • Catheter-associated urinary tract infections(CAUTI) • Surgical site infections (SSI) • Ventilator-associated pneumonia (VAP)

17. What’s different about the Compendium? • 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, APIC • The Joint Commission • American 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

18. 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.

19. Compendium and NPSG Comparison

20. 2009NPSG 07.04.01 Central Line-Associated Blood Stream Infections (CLABSI)

21. 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.

22. 2009 NPSG 07.04.01: Prevent Central Line–Associated Bloodstream Infections 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.

23. 2009 NPSG 07.04.01: Prevent Central Line–Associated Bloodstream Infections • 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. • 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. • 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).

24. 2009 NPSG 07.04.01: Prevent Central Line–Associated Bloodstream Infections 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. • 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.

25. 2009 NPSG 07.04.01: Prevent Central Line–Associated Bloodstream Infections 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. • 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. • 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.

26. 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.

27. 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.

28. Relationship of NPSG to the Compendium Compendium-CLABSI B. At insertion • Use maximal sterile barrier precautions during CVC insertion (A‐I). •  Use maximal sterile barrier precautions.   • A mask, cap, sterile gown, and sterile gloves are to be worn by all healthcare personnel involved in the catheter insertion procedure.   • The patient is to be covered with a large sterile drape during catheter insertion.

29. Survey Issues For NPSG 07.04.01-CLABSI

30. 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.

31. Frequently asked Question (FAQ) On NPSG 07.04.01 CLABSI Whole-house surveillance Q. Must we perform surveillance on all central lines, or is targeted surveillance okay? • 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. Documentation Q. 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

32. Summary

33. Educationon 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/

34. Summary 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.

35. Summary Compendium Web address: http://www.shea-online.org/about/compendium.cfm

36. 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:  KPodgorny@jointcommission.org