dnv gl healthcare · the dnv gl surveyors apply a comprehensive 18-point standard, with each...
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DNV GL © 2014 SAFER, SMARTER, GREENER DNV GL © 2014
DRAFT
DNV GL Healthcare
DNV GL © 2014 SAFER, SMARTER, GREENER DNV GL © 2014
Managing Infection Risk (MIR)
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DNV GL © 2013
DRAFT
DNV-GL snapshot
1864 2014
Safeguarding life, property and the environment
Enter Healthcare
1994 2008
Deeming Authority
100 16,000 500
Maritime
Offshore Power Generation Aviation/Defense
Food Transportation Healthcare
75,000 certifications issued globally
400+ Hospitals
DNV GL © 2013
DRAFT DRAFT
© Det Norske Veritas AS. All rights reserved Slide 4 26 May 2016
The Broader View of DNV GL
Reducing uncertainty, increasing safety Improving efficiency Enabling sustainability
Building trust
SAFER, SMARTER, GREENER
DNV GL © 2014
What does the MIR Standard designed to do?
Proactively manage and reduce risk associated with HAI’s within the organization
Reduce potential harm to patients, visitors, staff and the environment
Improve MIR performance beyond legislative requirements.
Promote continual improvement
Enable you to assure stakeholders of responsible and proportionate infection risk management
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The MIR Standard
Risk-based 18 elements – Performance-oriented
– Compatible with WHO and CDC guidelines
– Consistent with other international standards (e.g. ISO 9001/14001 and OHSAS 18001)
– Combines best practice from other industries with international standards
Includes elements specific for healthcare settings – Management
– Clinical
– Support
– Design
– Operation, maintenance and engineering
– Requirements from Infection prevention and control (IPC) management
– Performance management addressing quality and safety
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Rationale
Organizations need to provide assurance that risk is being managed effectively and proportionately
Demonstrate management holds responsibility to ensure risk is managed
Activities are proactively planned, conducted and reviewed
Integrates controls related to engineering, instructions and people
Necessary links are in place between related and dependent activities – i.e. is there a systematic process approach
Workers understand and follow the system to the required level
The system is ‘alive’ – it evolves and develops in a controlled and proactive manner
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18 Elements of MIR
5.1 Infection Risk Management System
5.2 Risk Assessment
5.3 Microbial Surveillance
5.4 Antimicrobial Use and Surveillance
5.5 Emergency Response and Contingency Planning
5.6 Accident and Incident Investigation
5.7 Personnel and Competency
5.8 Human Factors
5.9 Occupational Health
5.10 Healthcare Facility Requirements and Layout
5.11 Healthcare Environment
5.12 Equipment and Maintenance
5.13 Cleaning, Disinfection, Decontamination and Sterilization
5.14 Patient Care
5.15 Hand Hygiene
5.16 Clothing and Personal Protective Equipment
5.17 Movement and Transport
5.18 Security
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Requirements and Guidance (5)
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5.1.1 Infection risk management system
Infection risk management system
Infection risk management policy
Objectives, targets and program
Scope of service
Planning and resources
Roles, responsibilities and authorities (5.1.6) Top management
Management representative
Managing infection risk (MIR) committee
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System and policy in place to manage infection risks. Effective management and organization, management commitment and
leadership.
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Risk Assessment (5.2)
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2. Risk assessment
Planning and resources
Risk assessment timing and scope
Hazard identification
Risk assessment
Risk management
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Are effective mechanisms implemented to identify, assess and manage risks? Fundamental basis underpinning the MIR standard.
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Microbial Surveillance (5.3)
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3. Microbial surveillance
Infection surveillance program – Establish and maintain procedures
– Identify and implement measures for an effective infection surveillance program
– Identify and implement measures for an effective environmental surveillance program
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Looking at the awareness and measurement of infection risk data and trends in the hospitals. An essential measure to ensure performance is monitored and improved to effectively drive and target preventive
and response activities.
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Antimicrobial Use and Surveillance (5.4)
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4. Antimicrobial use and surveillance
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Program - Procedures in place for proactive
minimization and appropriate selection of antimicrobials
- Use of antimicrobials is effectively identified, specified, dispensed and monitored with regard to infection risk
- Establish an antimicrobial use committee
- Defined role and functions
Microbiology laboratory - Identify and have access to
appropriate microbiological laboratories
Use of antimicrobial in a responsible and sustainable manner.
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Emergency Response and Contingency Planning (5.5)
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5. Emergency response and contingency planning
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Identification of emergency scenarios
Emergency response and planning
Emergency plans
Emergency exercises and stimulations Contingency plans
Structures and mechanisms in place to cope with working outside the normal operating conditions
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GAP Assessment and CoE Certification
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Managing Infection Risk - Center of Excellence
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Preliminary / GAP Assessment vs. CoE Survey
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Preliminary / GAP assessment
Shorter duration
Reduced scope
Focus education and preparedness
Findings as presentation
Award of certificate of participation
CoE survey
Longer duration
Full scope
Focus on conformity to MIR requirements
Findings as list of NCs, observations, noteworthy efforts..
Award of MIR CoE designation
DNV GL © 2014
Slide 22
26 May 2016
MIR Assessment process
Record Checks
Verification Interviews
Interviews with Knowledgeable People
Program Verification Through
Physical Conditions
Tours
Audit Results
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Categories of Non-Conformities
Major An absence of one or more required system
elements or a situation which raises significant doubt that the services will meet specified requirements;
A group of category 2 NC’s indicating inadequate implementation or effectiveness of the system relevant to a requirement of the standard;
A category 2 NC that is persistent (or not corrected as agreed by the healthcare organization) shall be up-graded to category 1;
A situation that on the basis of available objective evidence may directly lead to unacceptable risk of patient harm or does not meet minimum standards of care.
Minor A lapse of either discipline or control during
the implementation of system/procedural requirements, which does not indicate a system breakdown or raise doubt that products or services will meet requirements. Overall system requirement is defined, implemented and effective.
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What is an Observation?
Potential problem
Risk
Inefficiency
Failure to apply best practice
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What is a Noteworthy Effort?
Adoption of best practice
Demonstrated improvement
High levels of commitment
Motivation
System optimisation
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Steps to Improvement
1 Organization submits an application for the MIR Program
– Program Content – “2015 Bundled Offer”
– Two Days Managing Infection Risk Training
– Two Day Gap Assessment
– Depending on Readiness the Surveyor will determine
timing for next survey potentially for Certification
2 Award of MIR Certification Circle of Excellence
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www.dnvgl.com
Contact Information
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Linda L. Spaulding RN, BC, CIC Linda.spaulding@incoandassociates.com 808-282-5738
DNV GL © 2014 SAFER, SMARTER, GREENER DNV GL © 2014
DRAFT
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