wyoming infection prevention
DESCRIPTION
Wyoming Infection Prevention. 4th Annual Infection Prevention Conference Casper, WY Russ Forney, PhD, MT(ASCP ) Healthcare Survey & Licensing Aging Division, WY Dept of Health. Good morning, we are here to survey your facility. Your Survey just started. Survey Summary (2012-2013). - PowerPoint PPT PresentationTRANSCRIPT
Wyoming Infection Prevention
4th Annual Infection Prevention ConferenceCasper, WY
Russ Forney, PhD, MT(ASCP)Healthcare Survey & Licensing
Aging Division, WY Dept of Health
Good morning, we are here to survey your facility...
Your Survey just started...
• Improved compliance- CONGRATULATIONS• Decrease in condition-level findings• Plan of corrections effectively implemented• Complex problems require ALL STAFF to solve
(infection control, medication, assessments)• Surveillance activities cited less often
Survey Summary (2012-2013)
WYOMING (N=19) REGION 8 (N=271) NATION (N=2164)
Type Description % Surveys Tag Description % Surveys Tag Description % Surveys
LTCASCACHCAH
Infection Control Program 56%
ACHLTCASCCAH
Infection Control Program 40%
ACHASCLTC
Medications 38%
ASCACHCAH
Infection Control (Safe, Sanitary Environment,
Surgical Services)
33%
LTCASCACHCAH
Medications 35%
ASCLTCACHCAH
Infection Control Program 33%
LTCASCACH
Patient RightsResident Rights 32%
ASCLTCACHCAH
Infection Control (Safe, Sanitary Environment,
Surgical Services)
35%
ASCLTCFACHCAH
Infection Control (Safe, Sanitary Environment,
Surgical Services)
28%
LTCASCACHCAH
Medications 32%
ASCLTCACHCAH
Infection Control (Condition) 22%
LTCASCACH
Patient RightsResident Rights 20%
LTCASCACHCAH
Infection Control (Condition) 12% ASC
LTCAdmission & Assessment 18%
ASCLTCACH
Advanced Directives, Consents
17%
• Sources of evidence– Observation– Interview– Document review
• Evaluation of findings• Determine if non-compliance exist• Intra-office QA process
Survey Process
• Infection control: A747 (ACH), C278 (CAH), Q240 (ASC)
• Surgical services A940 (ACH), C320 (CAH), Q060 (ASC)
• F441: Infection control (LTC)• Q181: Medication administration (ASC)
Frequent Findings (2012-2013)
Acute Care and Long-Term Care
• Surveillance activities• Sterile processing• High-level & environmental disinfection• Terminal OR cleaning• Sterile (controlled) storage & tracking• It is more difficult (complex processes) to
reprocess an endoscope than it is to use it
Infection Control: Acute Care
“Outside” specialties
• Surveillance activities: outcome & process• Data collection: active & passive• Environmental tour• Hand hygiene• Monitor all areas within the facility• Long-term care is a challenging infection
control setting - it is hard work!
Infection Control: LTC
• Infection control is a never-ending story, ongoing training for surveyors
• Increasing complexity in the survey process for all facilities, notably ACH (PSI program)
• Adding surveyors to the LTC team: formal training and OJT on site (survey)
HLS: The Next Generation
• Online IC database• Network• Annual IC conference• IP manual (2014)• Other facilities, QIO,
associations, WDH, regional affiliations (VA, ESRD, QIO)
Valuable Resources
Is he done yet?
Questions?
Russ Forney, PhD, Healthcare/CLIA [email protected] Licensing & SurveysAging DivisionWyoming Department of Health
Contact Information