a crosswalk between the regulatory alphabet soup meeting cms conditions of participation (cops) and...
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A Crosswalk Between The Regulatory Alphabet
SoupMeeting CMS Conditions of Participation (COPs) and
Interpretive Guidelines and JCAHO Standards and Elements
of Performance (EPs)9/13/05 Carolyn Fiutem, MT, CLS, CIC
Consistency in Both Camps
Both address organization and policies
Both address responsibilities of leadership
Both emphasize upstream solutions Both emphasize house-wide
implementation Wording different but principles are
the same, few exceptions
Program Comparisons
CMS COPs have 2 standards
1st affects organization and policies
2nd affects responsibilities of CEO, Medical Staff & DONs
JCAHO has 2 focuses
IC.1.10-6.10 focuses on IC programs & its components
IC.7.10-9.10 focuses on structure and resources
Expanded Guidelines/New Standards
Coordinate with hospital leadership to include all hospital staff, contract workers, and volunteers in infection surveillance and reporting
Incorporate antibiotic resistant/emerging infection surveillance in IC Program
Coordinate with hospital leadership/public health authorities for emergency preparedness
Examine surveillance methodologies for outpatient/short-stay surgical site infections
Compare and Contrast
Tag A-0338 CoP 482.42 – Sanitary Environment and Active Program
Clutter, filth, unappealing odors
Method for monitoring housekeeping, maintenance and other activities
IC.1.10 Coordinated process
Is the entire organization on board and integrated into the IC program?
Does the program share data and information? With whom and how?
Compare and contrast (cont)
482.42 CoP cont. How are patients/
HCWs educated? Who conducts
training/how evaluated?
Employee health – policies, illness monitoring and screening protocols
How is aseptic technique monitored?
IC.1.10 cont How do I
communicate with those who need to know? Is there a plan? System for notifying about HAI after patient leaves or when patient just admitted from another facility?
Does the program have a workable, dynamic IC plan with required elements?
Compare and Contrast (cont)
CoP 482.42 cont. Systems to ID and
assess patients/HCWs at risk
Specific measures of prevention, early detection, control, education, investigation
Evaluated, reviewed, revised
IC.5.10 Evaluate effectiveness of IC processes & strategies
Are evaluations performed in a timely fashion?
Is the process easy to understand?
Data presentation verbal and charts/graphs?
Solutions proposed?
Compare and Contrast (cont)
CoP 482.42 cont. Procedures for
working with local, state, federal health authorities in an emergency
P/P developed in coordination with federal, state and local emergency preparedness and health authorities to address communicable disease threats and outbreaks
IC.6.10 Emergency Preparedness
Did IC have input into emergency plan?
Does it address IC issues in enough detail to be useful?
Has IC worked with the community for designing response to large influx?
Can ED/staff verbalize their role in prevention/control during an emergency?
Compare and Contrast (cont.)
CoP 482.42 cont. The hospital’s IC program must
be integrated into its hospital-wide QAPI program.
PI.1.10 Collects data to monitor performance
16. IC surveillance and reporting
Compare and Contrast (cont)
CoP 482.42 cont. Orientation of all new hospital
personnel to infections, communicable diseases and the IC program
HR.2.10 Orientation for initial job training and information
Specific job duties and responsibilities and unit, setting or program-specific job duties and responsibilities related to safety and infection control
Compare and Contrast (cont)
CoP 482.42 cont. The hospital must provide a sanitary
environment to avoid sources and transmission of infections and communicable diseases.
EC.7.10 Manage utility risks The hospital designs, installs and
maintains ventilation equipment to provide appropriate pressures, air-exchanges and filtration efficiencies to control airborne contaminants
Compare and Contrast (cont)
Tag A-0339 CoP 482.42(a) The hospital must
designate in writing an individual or group, qualified through education, training, experience, AND certification or licensure as IC officers.
IC.7.10 IC program is managed effectively.
Hospital assigns responsibility for IC program activities based on goals and objectives
Qualifications may be met thru ongoing education, training, experience AND/OR certification
Compare and Contrast (cont)
482.42(a) cont. IC officer(s) must
develop and implement polices governing the control of infections and communicable diseases
IC.7.10 cont. Individual(s)
coordinates all infection prevention and control activities
Facilitates ongoing monitoring of the effectiveness of prevention/control activities and interventions
IC.4.10 Implement Strategies
7 required core interventions/strategies 1. Organization-wide hand hygiene 2. Reduce risk of infections related to
procedures, medical equipment and devices 3. Reduce potential for transmission 4. Screen LIPs, staff, students/trainees,
volunteers for vaccine preventable diseases 5. Referrals for assessment, testing,
immunization for those w/ infectious diseases 6. Referrals for assessment, testing,
immunization for those exposed 7. Animals in the health-care organization
IC.4.10 Cont.
Have all 7 strategies been addressed in the IC plan?
Reviewed by a multi-disciplinary team?
Leadership approved and committed resources?
Compare and Contrast (cont)
Tag A-0340 CoP 482.42(a)(1) Develop system for
identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.
IC.2.10 Identifies risks for the acquisition and transmission of infectious agents on an ongoing basis.
IC.3.10 Risks determine priorities and goals
Compare and Contrast (cont)
CoP482.42(a)(1) cont
System for identifying, investigating, reporting and preventing spread among patients, and hospital personnel including contract staff and volunteers, especially those occurring in clusters
IC.2.10 (cont) Surveillance
activities to ID infection prevention and control risks pertaining to patients, LIPs, staff, volunteers, and students/trainees, visitors and families, as warranted
IC.2.10 (cont)
IC risk assessment been performed to establish priorities?
Key staff participated? A consistent template used? Clear priorities? Leadership supportive? Have results been distributed? APIC/JCAHO to develop resource
book w/ templates
IC.3.10 (cont)
Are goals based on ICRA priorities? Number of goals correspond with available
resources? (Note: Many goals specified by CMS interpretive guidelines.)
Are the required goals included? (JCAHO, CMS, OSHA etc)
Specific measurable objectives for each goal?
Leadership approved of goals and objectives and committed resources and other support?
Example
Priority from ICRA – Hospital scores in upper quartile of NNIS data for VAPs in ICUs
JCAHO required goal – Minimize risk associated with procedures, medical equipment, and medical devices
Organizational Goal – Reduce Ventilator Associated Pneumonias
Objective – Reduce VAPs in Medical and Surgical ICUs by at least 10% by December 2006
Strategy – Use VAP bundle and implement all evidence-based procedures to minimize VAPs
Tag A-0341 CoP 482.42(a)(2)
No corresponding JCAHO standard/EP Maintain a log of all incidents related to
infections and communicable diseases Includes employee health Not just nosocomial infections Includes infections/communicable diseases
of patients and all staff (pt care, non-pt care, contract, volunteers)
Includes post-op infections in IPs who are D/C soon after surgery or outpatient surgery pts
APIC/CMS working on rewording this CoP and deleting the word “ALL” before incidents
Compare and Contrast (cont)
Tag A-0342 CoP 482.42(b) Responsibilities of
CEO, DON and Medical Staff
In-service training for IC problems
Implementing corrective action
Evaluate effectiveness
Document corrective actions and outcomes
IC.8.10 IC.8.10 Collaboration with IC Collaboration with IC programprogram
Are there multi-Are there multi-disciplinary projects disciplinary projects to help with the IC to help with the IC program?program?
IC.9.10 Resource IC.9.10 Resource AllocationAllocation
Can the IC team Can the IC team make the business make the business case to leadership case to leadership for a strong IC for a strong IC program?program?
Making the Business Case
IC is patient safety. IC good for the patient, physicians,
staff, visitors, families, volunteers. IC improves quality. IC reduces risk. IC protects the image of the
hospital. IC saves money!
IC and EC overlap
Construction and ICRAsConstruction and ICRAs Facility cleanliness and maintenanceFacility cleanliness and maintenance Hand hygiene Hand hygiene SharpsSharps SpillsSpills Sterilization and disinfectionSterilization and disinfection Sink placementSink placement Utilities – Air and waterUtilities – Air and water Equipment Management – biomed, Equipment Management – biomed,
SPDSPD
JCAHO take home messages
Written plan – updatedWritten plan – updated Continual risk assessmentsContinual risk assessments Multi-disciplinary/collaborativeMulti-disciplinary/collaborative Qualified staffQualified staff TracersTracers Environment of careEnvironment of care Integration into safety and quality Integration into safety and quality
programsprograms Use data to demonstrate improvementUse data to demonstrate improvement IC National Patient Safety GoalsIC National Patient Safety Goals
CMS take home message
Survey request list:Survey request list: Organizational chartOrganizational chart IC manualIC manual IC meeting minutesIC meeting minutes Log of infections/communicable Log of infections/communicable
diseasesdiseases Policies and proceduresPolicies and procedures Reporting and monitoring systemsReporting and monitoring systems Surveillance planSurveillance plan Emergency preparedness Emergency preparedness
documentationdocumentation
CMS message cont.
Focus areas: (Follow all CDC guidelines) Transmission-based precautions Surgical Services Food service Off-site locations Medical Records – recording of HAIs (ID, Doc,
Intervention, Tx) BBPs Hand Hygiene – 1 is a deficiency! Employee knowledge – “Tell me about…” BSIs Antibiotic Prophylaxis Protocol Campaign to Save 100,000 Lives
Thank You and Questions?
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