General Acute Care Hospital Relicensing Survey (GACHRLS)

1. General Acute Care Hospital Relicensing Survey (GACHRLS) Lisa Kilgore, MBA-HCM, BSBM, CIC Manager Epidemiology Scripps Memorial Hospital Encinitas 11/9/16

2. Objectives • Understand what is the General Acute Care Hospital Relicensing Survey (GACHRLS) • How to prep for the GACHRLS • How Infection Preventionist can be a resource during and after survey

3. What is a GACHRLS???? The California Department of Public Health (CDPH) developed the General Acute Care Hospital Relicensing Survey (GACHRLS) in order to work smarter with limited staff. GACHRLS is a combination of: • Medication Error Reduction Plan (MERP) • Patient Safety Licensing Survey (PSLS) • Title 22 California Hospital Regulation

4. Why More Torture? • Required by statute of Health & Safety Code Section 1279 (a) • Promote and ensure quality of care in hospitals • Verify compliance with State statutes and regulations • Ensure consistency in hospital survey methods BASICALLY TO PROVIDE US WITH 3-5 DAYS OF ENDLESS TORTURE!!!!! BRING ON THE BABY

5. Infection Prevention Prep Update or develop an entrance list binder of documents • Infection Control Program • All policies and procedures are updated • Review ICC minutes • Review all patients in all Precautions (know SB1058) • Hand hygiene program • Cleaning, disinfection and sterilization of equipment • OR / SPD / ENDO • NHSN (SSI, VAE, HAI, LABID)

6. DAYS 1-4 During the opening session, the lead surveyor introduced herself and her team which consisted of: • 1 Pharmacist • 1 Physician Consultant (Pediatrician) • 4 Registered Nurses (RN)

7. DAYS 1-4 Although only these 6 showed up at our door, any other hospital could also have the following: • Dietitian • Life Safety Code Surveyor • IC Specialist • Occupational Therapist • Consultants as needed • Records Administrator

8. DAY 1-4 The lead surveyor stated that each surveyor would have a main focus: • 1 RN: Main OR and procedural areas (ENDO, PACU, PREOP, SPD) and any floor where these patients go after leaving any of the above areas • 1 RN: L&D/Mother Baby/ NICU/OR • 2 RN: Med/Surg, Rehab (inpt/outpt), Definitive Observation unit, ED • Physician: Physician/Administration interviews, all units • Pharmacist: All units and Pharmacy

9. IP Interview/Involvement • Infection Control Committee • Reviewed minute • Previous PSLS, TJC, CMS survey findings • Policies, procedures (staff compliance) • IP biggest issues (hand hygiene compliance) • Cleaning/sterilization/disinfection • MERP/QAPIC/Quality Council • ICC minutes/reporting to the above committees • Antimicrobial Stewardship

10. IC GACHRLS Almost Findings AFL 11-32 reported procedures (who, what, when, how and how often) to what committees, outside hospitals, etc • Reviewed the Risk Assessment, minutes from the Surgery Supervisory committee and ICC to see what was reported and how often (Surgery Sup quarterly and PRN) • NHSN line listing of Denominator and Numerators • How do we know that we have infections (monthly SSI review (numerator)) • How do you know you catch all infections? (I don’t)

11. IC GACHRLS Almost Findings Cleaning/Disinfection: Know your cleaning supplies. What is cleaned and what is disinfected and how often • Inpatient equipment (Alaris pumps, glucometers etc) • Outpatient equipment (Rehab) Is the cleaner/disinfectant the same in the hospital? (outsourced, EVS, staff)

12. GACHRLS Survey Deficiency Action Plan • Your plan of action can be both temporary and permanent and should address the processes that lead to the deficiency cited. • Document the plan/procedure for implementing the plan of correction for the deficiency (what, how, when) • Have a monitoring process to ensure that the plan of correction is effective and the deficiency remains corrected (will not reoccur) and/or in compliance with regulatory requirements • Who is responsible for implementing the acceptable plan of correction? (Unit manager(not IP)) • Date when immediate corrective action will be completed. Normally not more than 30 calendar days from the date of the survey exit conference • Ensure that each deficiency/action plan is reported and documented to the appropriate committees (ICC, QAPIC, Quality, Safety)

13. IP GACHRLS Findings and Corrective Action Plan Neptune Drain: • In Central Sterile Processing Department had proper splash guard installed; however not anchored/no maintenance PM documented on the replacement of the box and no process of ownership as to who would request replacement when necessary • A monel wool was placed over the drain on 2/15/16 by engineering department • Monitoring of the PM to ensure compliance will done by manager of engineering during rounds in CPD once a week for the first month and then once a month for 2 months • The monitoring will start 2/15/16 and complete on 5/16/16 • Preventative maintenance of the wool covers will occur w/PM reports 2x year to ICC and Safety committee

14. IP GACHRLSFindings and Corrective Action Plan Transport of Instruments: • The transport of soiled instruments from the OR to CPD does not meet hospital P&P for rigid container labeled with orange biohazard symbol. Know what is recommended and what is regulatory and make sure you follow what is in your policies or procedures • Proper transport containers were purchased by OR/CPD manager on 2/8/16 • OR/CPD manager will audit/observe 30 transports every month for 3 months to ensure utilization of new container and permanent application of biohazard label on outside of container with every transport • The new process will be monitored for 3 months starting 2/8/16 and will complete on 4/30/16 • Compliance will be reported at QAPIC for three months (April-June)

15. IP GACHRLSFindings and Corrective Action Plan PPE: • Employee entered Enhanced Contact Precautions (ECP) room without PPE violating hospital Standard and Transmission Based Precautions policy • Immediate education/reinforcement was performed by IP with Staff during huddles, standups and staff meetings regarding appropriate PPE • The Manager and Director will perform 30 audits/observations per month for 3 months (Feb-April). 90% compliance or higher to ensure compliance with process • The new process will be monitored for 3 months starting 2/2/16 ending 4/30/16 • Report out at Infection Control committee meeting 7/15/16

16. IP GACHRLSFindings and Corrective Action Plan Equipment labeled with clean stickers: • Clean equipment was inconsistently labeled with clean stickers • CPD and Supply chain staff went to each equipment room and ensured that clean labels were on all appropriate equipment. Re-education focused on the policy principle that all equipment that has been properly cleaned must have a “CLEAN” sticker placed on it. NO equipment is to be delivered without a “CLEAN” sticker • Weekly random audits will be done by CPD/OR/PACU/Supply Chain managers for six weeks beginning 2/2/16 with 100% compliance expected • The new process will be monitored for six weeks beginning 2/2/16 and ending 3/14/16 • Compliance will be reported at the 4/15/16 Infection Control Committee

17. References https://www.cdph.ca.gov/programs/LnC/Pages/GeneralAcuteCareRelicensingSurvey.aspx • Relicensing survey overview • Process Guidelines • Regulations w/Survey Procedures • General Entrance List • Pharmacy Entrance List • Survey Activity Schedule • Medication Pass Worksheet • Relicensing Evaluation Form

18. Thank you!