Transcript New York State Department of Health Center for Medicaid Medicare Services [CMS] All Cause Corrective Action Stony Brook Medicine “The Stony Brook Way is My.

New York State Department of Health
Center for Medicaid Medicare Services
[CMS]
All Cause Corrective Action
Stony Brook Medicine
“The Stony Brook Way is My Way”
DOH References of Deficiency:
1. Allegations of Sexual, Physical, or Psychological
Abuse
2. Infection Control Practices
3. Intravenous Therapy and Blood Product
Administration
4. HIPAA, as it relates to PHI Disclosure
5. Code Cart Standardization
“The Stony Brook Way is My Way”
IMPLEMENTATION /COMMUNICATION
STRATEGY
1.
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3.
4.
5.
Didactic education
Skills based training and Simulation
Attestation- confirmed completion
Validation- check performance
Outcomes- compliance
“The Stony Brook Way is My Way”
CMS ALLEGATION SURVEY
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DOH for CMS Allegation survey 4/28/15 – 5/4/15
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Finding related to process for investigation of patient complaints of
Abuse & Neglect by a Staff member
• Actions:
 New Policy implemented prior to DOH exit (policy #RI 0057)
 Education to front line, managers, supervisors, directors & medical
staff via PPs, LMS, and continuing through annual re-certifications
and new employee orientation
 Abuse Complaint checklist to document actions
“The Stony Brook Way is My Way”
CMS REPORT 5/13/2015
• CMS document received evening of 6/3/2015 (on day 3 of TJC Survey)
• Follow up actions and clarification statements to be submitted by
6/15/2015
• Requires 100% education : Medical Staff must complete to 100% by
6/15/2015
• Requires 100% monitoring of responses to Abuse & Neglect complaints (13
to date since DOH visit)
• Requires feedback to Departments on Abuse & Neglect complaints
• Requires tracking & trending by department and individual
“The Stony Brook Way is My Way”
HEALTHCARE EPIDEMIOLOGY DEPARTMENT
Administrative Policy on Isolation Precautions IC 0006
As soon as patients are identified as needing isolation:
• Yellow card / chart, dedicated stethoscope / thermometer
• All rooms must have a Personal Protection Equipment [PPE] cabinet
in or in close proximity to the entryway
• Cabinets must be stocked with gowns, gloves, surgical masks,
goggles and / or face shields
• All HCWs are responsible for following the isolation precautions
delineated in the Hospital Policy and reminding other HCWs to do the
same
• Families must be educated re: On hand hygiene practices and
Patients isolation
Infection Control is in Your Hands
HEALTHCARE EPIDEMIOLOGY DEPARTMENT
All patients, regardless of status:
• inpatient
• outpatient
• observation
Must be placed on the correct isolation precautions based
upon:
• personal history
• clinical presentation
• isolation code on Banner Bar
Infection Control is in Your Hands
HEALTHCARE EPIDEMIOLOGY DEPARTMENT
Isolation Card (front)
DISEASE - SPECIFIC PRECAUTIONS
Visitors
VISITANTES: FAVOR DE ANUNCIARSE A LA ENFERMERA DE PISO ANTES DE ENTRAR AL CUARTO
MASKS □ No □ Yes
Fitted N95 Respirator
□ No □ Yes
GOWNS
□ No □ Yes
REPORT TO NURSES’ STATION BEFORE ENTERING ROOM
□ For all those close to patient
□ For all persons entering
□ If soiling is likely
□ For all persons entering
room
room
GOGGLES / FACE
SHIELD
□ No □ Yes
GLOVES
□ No □ Yes
□
□
For touching infective material
For all persons entering room
Wash hands with soap and water only.
□
□
For all those close to patient
For all persons entering room
□ No □ Yes
Hands must be washed before donning and after removing gloves, touching the patient
or patient’s environment, and before taking care of another patient.
Private room indicated?
NURSE
□ No □ Yes
INFECTION CONTROL PRACTITIONER
Infection Control is in Your Hands
HA2N002 (4/18/11)
DEPHEALTHCARE EPIDEMIOLOGY DEPARTMENT
ORMATICS
Administrative Policy on Hand Hygiene IC 0003
Hand Hygiene is performed:
• Upon entering & exiting patient rooms
• Before and after any contact with patient / environment, regardless
of +/- isolation status
• In between dirty and clean procedures
• Between separate portions of the physical exam re: clean vs dirty
• OK to foam when entering a C diff room, but must wash hands
with SOAP / WATER upon exiting
Families must be educated on hand hygiene practices
Infection Control is in Your Hands
HEALTHCARE EPIDEMIOLOGY DEPARTMENT
Administrative Policy on Infection Control in patient
transporting IC 0007
Patients on isolation must be transported using practices that minimize
cross contamination
If patient is on isolation, the transporter must:
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perform hand hygiene, don correct PPE identified on the isolation yellow card before
entering room
Bring clean transfer equipment into the room, transfer patient to stretcher or wheelchair
as indicated
cover patient with clean sheet
remove isolation garb before exiting room, perform hand hygiene
When transferring patient on occupied bed, wipe the side rails and all accompanying
equipment with antimicrobial (purple) wipes, allowing for 2 minute dwell time prior to
exiting the room
Infection Control is in Your Hands
HEALTHCARE EPIDEMIOLOGY DEPARTMENT
Health Care Providers are NOT to carry multi-dose vials in
pockets or case (pharmacy policy modified):
• from patient to patient
• from room to room
• when used on a patient with an infection, discard after use
Use single-dose containers whenever possible
When single-dose dispensers are not available:
• maintain aseptic technique
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perform hand hygiene
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prevent tip of dispenser from touching the patient
• wipe down container with antimicrobial (purple) wipes in between
every patient encounter and prior to returning it to the case.
Infection Control is in Your Hands
HEALTHCARE EPIDEMIOLOGY DEPARTMENT
SBU Hospital Infection Control Policies
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Hand Hygiene IC 0003
Multidrug Resistant Organisms (M-RO) IC 0010
Patient Care Equipment Cleaning IC 0013
Infection Control In Patient Transporting IC 0007
Isolation Precautions IC 0006
Prevention and Control of Clostridium defficile IC 0022
Prevention and Transmission of M. Tuberculosis infection IC
0011
MM0012 Multiple Dose Vials, Multiple Use Containers
IC0012 Standard Precautions
Infection Control is in Your Hands
All consultants [MDs, NPs, PAs, etc] will
notify primary nurse of their arrival prior to
entering patient room in ED and on the Units:
“I’m here to see patient ____. Is there
anything I should know?”
“The Stony Brook Way is My Way”
IV THERAPY AND BLOOD ADMINISTRATION
 Audit and analysis of all IV and Blood
Administration Policies
 Development of educational materials
aligned with best practices and SBUH
policies
• Development of Skills Training stations
• Development of Simulation scenarios
• Training of Auditors
• Systematic ongoing monitoring
“The Stony Brook Way is My Way”
HIPAA COMPLIANCE: PROTECTED
HEALTHCARE INFORMATION
 Removed complete patient name from
slave monitors
• Rolling computer carts: instructing and
auditing for open EMRs with PHI on the
screen
• Education on the proper communication of
PHI, with instruction for sensitivity to the
environment and other people: only
permitted use of incidental disclosure
“The Stony Brook Way is My Way”
CODE CART STANDARDIZATION
 All Pediatric and Adult Code Carts now
include the appropriate Zoll Pads
 Pediatric Code Cart now contains two sets
of Zoll Pads: Children less than 8 years of
age and over 8 years of age
 All Code Carts now have consistent Code
Cart checklists
“The Stony Brook Way is My Way”
ALL CAUSE CORRECTIVE ACTIONS
Accountability
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Attestation of all staff by 6/15/2015
Validation of training and education 6/15-6/20/2015
Remediation directives-as it occurs
Behavior-Based Expectations- continuous
“The Stony Brook Way is My Way”
Please sign and date the attestation faxed to you
EMAIL to: [email protected]
Type your name - LAST NAME, FIRST NAME in the
SUBJECT of email
If you are unable to email, please fax to:
631-706-3329