1. ANNA JERSEY NORTH CHAPTER 126 Presents: Presents: CMS CONDITIONS OF COVERAGE CMS CONDITIONS OF COVERAGE Climbing the Mountain Climbing the Mountain March 12, 2009 March 12, 2009

2. Infection Control Infection control practices within the dialysis unit CDC components of a comprehensive infection control program Infection control precautions designed to prevent the transmission of blood borne pathogens Training, education and surveillance for infections

3. Methods to Reduce transmission of infection Standard precautions Standard precautions PPE – personal protective equipment PPE – personal protective equipment Hand Hygiene Hand Hygiene

4. Recommendations for Placement and Management of intravascular catheters Health care worker training and education Health care worker training and education Appropriate measures for the prevention of intravascular catheter related infections Appropriate measures for the prevention of intravascular catheter related infections Surveillance of CRBSI – catheter related bloodstream infections Surveillance of CRBSI – catheter related bloodstream infections

5. Assessment Tools/Plan of Care Changes to the comprehensive Interdisciplinary Assessment. Changes to the comprehensive Interdisciplinary Assessment. Members of the Interdisciplinary team Members of the Interdisciplinary team Measures Assessment Tool (MAT) – Required Components Measures Assessment Tool (MAT) – Required Components Timelines: Began 10/14/2008 Timelines: Began 10/14/2008 Initial assessments for new patients Initial assessments for new patients Reassessment for new patients Reassessment for new patients

6. Changes to the Plan of Care Components of POC Components of POC Reviewing and developing the POC Reviewing and developing the POC Criteria for stable vs. unstable patients Criteria for stable vs. unstable patients Monthly review of unstable patients Monthly review of unstable patients

7. New Patients/Existing Patients Responsibility: Medical Director Responsibility: Medical Director Implementation process for new patients and integration of existing patients Implementation process for new patients and integration of existing patients Patient Needs: Comprehensive assessments, Initial assessments, POC, and adjustment to POC. Patient Needs: Comprehensive assessments, Initial assessments, POC, and adjustment to POC.

8. Quality Assessment Performance Improvement QAPI – What is it? QAPI – What is it? Data driven process to assess and improve care. Performance measurement tools: Performance measurement tools: MAT (measure assessment tool) and CPM (clinical performance measures) Interdisciplinary team members responsibilities, including Medical Director Interdisciplinary team members responsibilities, including Medical Director

9. Quality Indicators Measure, analyze, track, trending = Measure, analyze, track, trending = OUTCOME OUTCOME

10. Facility Reports Dialysis Facility Report (DFR) Dialysis Facility Report (DFR) Facility Compare Facility Compare Network Reporting Network Reporting

11. Root Cause Analysis Used to correct identified problems Developing Improvement Action Plan Implementing improvement Plan Evaluation Good Outcome

12. Thank-you Brenda Boston-Hudson, RN NYS Department of Health 90 Church Street 15 th Floor New York, NY 10007 212 417-5935 beb08@health.state.ny.us