1. Collaborative to Reduce Healthcare Associated Infections
Alignment with National Initiatives

2. Joint Commission National Patient Safety Goals
2008 NPSG Goal 7
Reduce the risk of healthcare-associated infections
Comply with WHO/CDC hand hygiene guidelines
Manage as sentinel events all identified cases of unanticipated death or permanent loss of function associated with a healthcare-associated infection

3. Joint Commission 2009 National Patient Safety Goals
3 new requirements related to preventing healthcare-associated infections:
Multiple drug resistant organisms
Central line associated bloodstream infections
Surgical site infections
Align with Safety Center initiatives

4. Joint Commission 2009 National Patient Safety Goals
Prescriptive elements of performance based on CDC recommendations
One-year phase-in period with defined expectations for planning, development, testing at 3,6,9 months with full compliance by January 2010
Each requires pilot testing in at least one unit by October 2009
Each requires specific patient /family education

5. Joint Commission 2009 National Patient Safety Goals
Goal NEW
Implement evidence based practices to prevent health care-associated infections due to multi-drug resistant organisms
MDRO risk assessments and surveillance
Staff and practitioner education
Educate patients and families who are infected or colonized
Measure/monitor MDRO prevention processes and outcomes including MDRO infection rates and compliance with evidence based guidelines
Evaluation of the education programs for staff
Share surveillance data with leaders, staff, LIPs
Lab-based alert system that identifies new MDRO patients and alert system for readmissions and transfers

6. Joint Commission 2009 National Patient Safety Goals
Goal Implement evidence-based guidelines to prevent central line-associated bloodstream infections.
Policies and procedures aligned with evidence-based standards
Periodic risk assessments,measure CLBSI rates, monitor compliance with evidence-based guidelines
Share infection rates and compliance data with key stakeholders including leaders, staff, LIPs
Standard insertion protocol and checklist (Document)
Use bundles – standardized cart, hand hygiene, full barrier precaution, avoid femoral site, chlorhexidine prep
Use standardized protocol to disinfect catheter hubs and injection ports before accessing. (Document)
Evaluate need for catheter routinely and remove nonessential

7. Joint Commission 2009 National Patient Safety Goals
Goal Implement best practices for preventing surgical site infections
Implement policies and practices that meet regulatory requirements and align with evidence based standards (Document)
Conduct periodic risk assessments, select and monitor measures, monitor compliance with evidence based guidelines
SSI rates measured for the first 30 days post op and for first year if implantable device
Share SSI rate data and prevention outcome measures with leaders, staff and LIPs
Antibiotic prophylaxis according to evidence based standards
When hair removal necessary, hospital uses clippers or depilatories (no shaving)

8. Joint Commission 2009 National Patient Safety Goals
Goal 13 Encourage patients active involvement in their own care as a patient safety strategy EP
Patient and family are educated on available reporting methods for concerns related to care, treatment, services and patient safety issues
Provide patient with information on infection control measures for hand hygiene, respiratory hygiene, and contact precautions according to patient condition on admission or as soon as possible (Document)
Surgical patients educated on hospital measures to prevent adverse events in surgery such as patient identification, prevention of SSI, marking the site (Document)
Hospital encourages patients/families to report concerns about safety

9. Joint Commission 2009 National Patient Safety Goals
Updates, changes and new requirements to other existing safety goals for
Medication Reconciliation
Transfusion errors
Universal Protocol for surgery and invasive procedures

10. CMS Hospital Public Reporting
measures reported including SCIP process measures
new measures
Most are calculated by CMS using Medicare administrative claims data versus clinical chart abstraction
AHRQ quality and patient safety indicators software

11. Medicare Hospital-Acquired Conditions
The Deficit Reduction Act of 2005 required CMS to identify at least two preventable complications of care that could cause patients to be assigned to a higher paying DRG.
8 conditions adopted in CMS IPPS 2008 final rule:
Object left in during surgery
Air embolism
Blood incompatibility
Catheter associated urinary tract infections
Pressure ulcers
Vascular catheter associated infections
Mediastinitis after coronary artery bypass graft
Hospital-acquired injuries (including fractures, dislocations, intracranial injury, crushing injury, and burns)
AHA is very concerned about the expansion of this list. We disagree with CMS’ decision to include more conditions on this list beyond what was recommended in the proposed rule. We believe that it is not always possible to know whether a condition is POA, and we have grave concerns about the ability of hospitals to implement POA coding for some of these conditions, such as pressure ulcers and catheter-associates urinary tract infections. Several of the selected conditions are not always reasonably preventable. Additionally, we are concerned that CMS refocused its discussion from injuries sustained from falls in the proposed rule to a broader category of injuries in the final rule. The agency did not receive the benefit of public comment and review on these conditions because they were not specifically listed in the proposed rule. We do not believe that burns, intracranial injuries or some of the other injuries listed by CMS are always related to falls in the hospital, and we do not believe they meet the statutory requirements of this provision as we are not aware of any evidence-based guidelines for the prevention of these injuries.

12. Medicare Hospital-Acquired Conditions
2009 CMS selected 2 additional hospital acquired conditions. Unless present on admission, if present these conditions will not result in a higher DRG complications payment rate.
Poor Glycemic control in certain conditions
Deep-vein thrombosis/pulmonary embolism following certain orthopedic surgery cases
Expanded SSI to include certain orthopedic and bariatric surgeries

13. Tennessee Statutes Public Chapter 904
Hospital reporting to CDC NHSN on central line bloodstream infection rates in ICU’s
First public report released after 12 months of data (Jan 2008-Jan 2009)
Public Chapter Passed May 2008
Requires local MRSA risk assessments by all licensed healthcare facilities (hospitals, nursing homes, ambulatory surgery)
Facilities to implement prevention and reduction strategies based on local risk.
Strategies align with CDC guidelines. MAY include active surveillance testing

14. Alignment with National Initiatives
IHI 5 Million Lives Campaign
QIO 9th Scope of Work
CDC and professional society guidelines
National Quality Forum Hospital Safe Practices

15. Alignment with National Initiatives
Keep Patients as our North Star
But use the synergy of alignment with other requirements and national initiatives to build greater focus for your teams, elevate your team’s efforts on the priority list within the system and get the resources needed for your work!