Transcript Health Facility Compliance Patient Quality Care Unit

 1864
agreement
◦ Agreement between CMS and
the State
◦ DADS is the primary State
agency
◦ DSHS draws moneys from
DADS
 The
federal government
(HCFA/CMS) was told that they
would HAVE to work with the
States.
 Survey
and Certification gets
 ½ of one cent of every dollar
A very brief overview
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To promote patient safety
◦ Creating a safe environment
◦ Track and analyze
 By tracking and analysis, we can all learn to avoid
adverse events/sentinel events in the future
◦ Better care
 Lower costs
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Surveys to evaluate compliance with 3
Conditions of Participation relating to
reducing Hospital Acquired Conditions and
readmissions:
◦ Quality Assessment Performance Improvement
◦ Infection Control
◦ Discharge Planning
INFECTION CONTROL
TOOL
 The goal is to promote HAI prevention and patient safety in hospitals
 Patient Focused
 Tool is intended to be used by hospital surveyors to assess the
minimum health and safety standards needed for hospitals to meet
the Medicare Conditions of Participation for Infection Control
 The tool will be accessible for hospitals for self assessment of
infection control compliance
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QAPI- raw data,
frequency of
meetings, policies
and procedures,
outcomes,
corrective action
Credentialing of
Infection Control
Officer
Medical record
review
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Infection Control
Officer
Department Heads
Patient/family
interviews
Direct care staff
Physicians
Ancillary staff
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Basic Infection Control
Delivery of Care
Isolation
Invasive Procedures
Sterile Processing
Environment
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The three key elements to determine
compliance with any of the Conditions of
Participation are:
Record Review
Interview, and
Observation
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The goal is to promote HAI prevention
and patient safety in hospitals
Patient Focused
The Survey Tool is intended to be used
by hospital surveyors to assess the
minimum health and safety standards
needed for hospitals to meet the
Medicare Conditions of Participation for
Infection Control
This tool will be accessible for hospitals
for self assessment of infection control
compliance

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QAPI- raw data,
frequency of
meetings, policies
and procedures,
outcomes,
corrective action
Credentialing of
Infection Control
Officer
Medical records
Department Heads
 Patient/family interviews
 Infection Control Officer
 Direct care staff
 Physicians
 Ancillary staff
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Basic Infection Control
Delivery of Care
Isolation
Invasive Procedures
Sterile Processing
Environment
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The following is a recent article stressing the
importance of infection control and what can
happen when basic control procedures are
not utilized.
July12, 2012 — Repeated use of single-use medication vials has been linked to the transmission of life-threatening
Staphylococcus aureus infection in 10 patients treated for pain in outpatient clinics in Arizona and Delaware, according
to a new study from the US Centers for Disease Control and Prevention (CDC).
Melissa Schaefer, MD, a medical officer in the CDC's Division of Healthcare Quality Promotion, and colleagues with the
CDC and the Arizona Department of Health Services published their findings in the July 13 issue of the Morbidity and
Mortality Weekly Report.
Three patients initially treated at a single pain management clinic in Arizona were hospitalized from 9 to 41 days for S
aureus infections after injection of a contrast solution from the same single-dose vial. A fourth patient who received an
injection from the same vial was found deceased 6 days after the injection; invasive S aureus infection could not be
ruled out.
In Delaware, 7 patients with S aureus–based septic arthritis or bursitis were admitted to the hospital. All had received
joint injections at the same outpatient clinic during the same recent 2-day period. An additional 3 patients who
received injections at the clinic during this period required outpatient treatment for symptoms that suggested infection.
The researchers found that reuse of a single-dose vial of bupivacaine among multiple patients was the only breach of
safe practice at this clinic.
According to the CDC, these outbreaks demonstrate the serious consequences that can result from misuse of singledose vials. These vials typically do not contain preservatives and are intended for single-use injection to avoid risk for
infection.
The appropriate use of single-dose vials includes prompt use of the contents in a single patient during a single
procedure and immediate disposal of the vial and any remaining contents, the CDC authors report. They add that
difficulties in acquiring the appropriately sized medication vials, frequently a result of medication shortages, often lead
to these safety breaches. "These outbreaks could be avoided if smaller medication vial sizes that better fit procedural
needs were manufactured.”
According to the CDC, 20 outbreaks associated with multiple-patient use of single-use or single-dose vials have been
reported since 2007. "These investigations help remind health-care providers of infection prevention practices that are
critical for patient safety," they note.
"When outbreaks or clusters are identified, prompt notification of public health authorities is imperative to ensure that
appropriate case-finding activities and infection control measures are implemented to prevent additional harm," they
conclude.
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Communication
Organization
Teamwork and Cooperation
Support of the Medical Staff and Governing
Body
Action
Assessing hospital compliance with the
Condition of Participation for Quality
Assessment & Performance Improvement
(QAPI)
Survey staff will utilize a specific tool
Governing Body and Medical Executive By
laws
Hospital Rules and Regulations
Minutes – Governing Body, Medical
Executive, Quality Assurance Performance
Improvement
Casual Analysis or Root Cause Analysis
policy and procedures
QAPI program evaluation of contracted
services
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QAPI plan for current and previous year
List of events (i.e. unusual occurrences,
incidents, sentinel events or serious adverse
events) for past 24 months
List of Casual Analysis or Root Cause Analysis
List of all QAPI policies and procedures
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Three quality indicator traces the facility is
tracking will be chosen for review (i.e.
discharge summary, hospital acquired
infection)
Data for the past 12months will be requested
for the three indicators chosen
Data is evaluated for how is collected and
what is being done with this data
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Casual Analysis or Root Cause Analysis
Three analysis will be chosen for review
When reviewing analysis, surveyors will be
assessing: what happened, why it happened,
what facility identify, if reported to proper
agency and what steps facility implemented
to prevent this from happening again.
If facility is working on a project (i.e. Certified
Stroke Center, Certified Joint Replacement
Center):
 How is QAPI involved with the project.
 What data is being collected
 Is the project appropriate for services being
provided
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New surveyor worksheet and survey
process alone will NOT improve outcomes
 Renewed focus on discharge planning with
increased surveillance and enforcement
 Hospitals will work to self-assess and
improve their own processes
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GOAL = Reduction of preventable
readmissions
 Stay
Connected
 Communicate
 Collaborate
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Make reducing Hospital Acquired
Conditions and readmissions a priority for
the governing body, hospital leadership,
clinicians and all staff
Support clinicians and engage patients and
families in making care safer
Learn from and share experiences with
others