1. A Crosswalk Between The Regulatory Alphabet Soup Meeting CMS Conditions of Participation (COPs) and Interpretive Guidelines and JCAHO Standards and Elements of Performance (EPs) 9/13/05 Carolyn Fiutem, MT, CLS, CIC

2. 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

3. Program Comparisons CMS COPs have 2 standards 1 st affects organization and policies 2 nd 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

4. 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

5. 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?

6. 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?

7. 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?

8. 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?

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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?

16. 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

17. 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

18. 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

19. 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?

20. 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

21. 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

22. 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 Collaboration with IC program IC.8.10 Collaboration with IC program Are there multi- disciplinary projects to help with the IC program? Are there multi- disciplinary projects to help with the IC program? IC.9.10 Resource Allocation IC.9.10 Resource Allocation Can the IC team make the business case to leadership for a strong IC program? Can the IC team make the business case to leadership for a strong IC program?

23. 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!

24. IC and EC overlap Construction and ICRAs Construction and ICRAs Facility cleanliness and maintenance Facility cleanliness and maintenance Hand hygiene Hand hygiene Sharps Sharps Spills Spills Sterilization and disinfection Sterilization and disinfection Sink placement Sink placement Utilities – Air and water Utilities – Air and water Equipment Management – biomed, SPD Equipment Management – biomed, SPD

25. JCAHO take home messages Written plan – updated Written plan – updated Continual risk assessments Continual risk assessments Multi-disciplinary/collaborative Multi-disciplinary/collaborative Qualified staff Qualified staff Tracers Tracers Environment of care Environment of care Integration into safety and quality programs Integration into safety and quality programs Use data to demonstrate improvement Use data to demonstrate improvement IC National Patient Safety Goals IC National Patient Safety Goals

26. CMS take home message Survey request list: Survey request list: Organizational chart Organizational chart IC manual IC manual IC meeting minutes IC meeting minutes Log of infections/communicable diseases Log of infections/communicable diseases Policies and procedures Policies and procedures Reporting and monitoring systems Reporting and monitoring systems Surveillance plan Surveillance plan Emergency preparedness documentation Emergency preparedness documentation

27. 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

28. Thank You and Questions?