The Joint Commission NPSG

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The Joint CommissionNPSG
NPSG 7 Compliance The Dr. Seuss Way
Annette Moore RN CIC Charlotte Wheeler RN BSN CIC
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Baptist St. Anthonys Health SystemAmarillo Texas
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Our House

• 451 Bed Acute Care Hospital
• 48 Critical care beds
• 20 Bed Level 1 NICU unit
• 15,000 surgical procedures/year
• Free Standing Cancer Center
• 2 Ambulatory Surgery Centers
• 2 Ambulatory Care Clinics
• Inpatient Rehab
• Target Surveillance with
• 2 AWESOME FTE 1 FTE per 225 bed

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The Journey Begins

• 2008 TJC unveils their 2009 NPSG with timeline
  for implementation
• Our Response.
• Leadership assigns Committees for all NPSG
• Brainstorming for Compliance with NPSG includes
  Education Strategy
• Education Strategy ----
• Think out of the box EXTREME EDUCATION

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The ChallengeEducating Out of the Box

• Staff Education Overload
• Reaching all appropriate employees
• Making NPSG FUN and Memorable
• NPSG Team Strategy
• Comic Book
• Each NPSG will use one of
• Dr. Seuss Book as a guide
• NPSG 7 - Cat in the Hat

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Fun Facts For Adults Do your Work or
Play at the Job?

• Playing/Fun not just for Kids
• Its the doorway to learning
• Our mind is more alert and can learn faster and
  without barriers
• Connects us to others provides a relaxed
  environment and works as team building
• Benefits of Playing and Fun at work
• keeps you functional when under stress
• refreshes your mind and body
• encourages teamwork
• helps you see problems in new ways
• triggers creativity and innovation
• increases energy and prevents burnout
• "People rarely succeed unless they have fun in
  what they are doing."
• Dale Carnegie
• http//www.helpguide.org/life/creative_play_fun_ga
  mes.htm

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TJC 2009 Time LineMDRO, CL and SSI

• April 1st Leadership Assigns Responsibility and
  oversight for compliance
• July 1st - Implementation Work plan in Place
  including resources needed
• October 1st - Pilot testing in at least one
  clinical unit
• January 1st 2010 Elements of performance fully
  implemented across the hospital

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Initial Assessment NPSG 7

• Assessment of processes in place meeting NPSG
  requirement
• Hand Hygiene Program and Audits in place ( less
  emphasis in 2010 ( observation)
• Sentinel Event (deleted in 2010) Process in place
• MDRO Flagging Process in place
• Central line Protocol/ IHI Bundle Process in
  place
• SCIP Protocol/Bundles Process in Place
• First Glance Were in GREAT SHAPE

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On a Closer LookMDRO

• No Patient education implemented or documentation
  process
• Measurement tool?
• No formal education for staff
• Measurement tool?
• Isolation compliance hit and miss
• Measurement tool
• Venue for presenting quarterly MDRO surveillance
• MDRO Flagging only on one system, not the system
  nurses use often

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Closer Look Central Lines Prevention Element

• Only receiving 30 checklist/month from 150/month
  procedures
• Central line carts on the floor/ checklist not
  used
• OR not using checklist
• No patient education or documentation process
• Protocol does not include scrub the hub
• No formal education for staff

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The Closer LookSurgical Site Infection
Prevention

• Education to patient includes what to expect in
  surgery /No education/documentation for patient
  on prevention measures for SSI prevention
• Measurement tool
• No formal education for staff except in OR
• Measurement tool

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The NPSG 7 Organizational Team

• Met BiWeekly April - July
• Nursing
• Critical Care
• OR
• Special Procedures
• Documentation Team
• Case Management
• Quality Improvement

All Responsible for taking 1 element of NPSG
using The Cat in the Hat as a format Resulting in
a Fun Rhyme for NPSG
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BSA NPSG Comic Book
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NPSG The Comic Book and Tools

• July 1st NPSG Comic Book Online for staff
  access
• Dec 31st Deadline complete education and post
  test
• 2010 Jan 1st Compliance Audits
• 2010 Jan 1st NPSG 7 Monthly Education
• NPSG 7 Education starts in New Nurse
  Orientation
• Unit Education and bookmarks

Sample of all NPSG Comic Book on
Presentation Table
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Staff Education

• Plan A Housewide Education during Flu Vaccine
  Administration
• Budget cuts and Flu Shortage
• Plan B Monthly Snippet Education
• MDRO, Cline, SSI
• IP develops and sends monthly
• One Page Information
• Director/Educator responsible for staff education
  on unit
• Information kept on Education Board/30 days
• 7 NPSG Notebook available on floor and online
• Measurement for Staff Education
• Net learning Post Test
• Bookmark, comic NPSG 7 to staff in staff meetings

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Meet The Cat BSA Infection Preventionist
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Infection PreventionNPSG 7
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THING 1 Hand Hygiene NPSG 07.01
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Hand Hygiene ComponentsHousewide Goal 95 or gt

• BSA Hand Hygiene Program
• Gel to Excel
• Program based upon CDC guidelines
• BSA Gold Standard
• Hand Hygiene every time you enter pt room
• Patient Education
• Its Ok to Ask
• Hand Hygiene Audits monthly
• Each Clinical Dept Director responsible to submit
  a minimum of 10/month
• Outcome Audits provided monthly to each unit
• Nursing and Ancillary Directors Performance
  Evaluation depends upon their units HH rate
• Secret Shoppers and Unit Observation
• To keep the balance and to prevent Directors
  skewed perceptions

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Patient EducationIts Ok to Ask
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Hand Hygiene Audit tool
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Hand Hygiene Outcomes
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Thing 3 Multiple Drug Resistant Organisms NPSG
07.03.01
As Infection Control we must prevent, An HAI in
any event MDROs are with us you see, Both MRSA
and VRE. The strategy is simple and quite
precise, Including hand hygiene or cleaning a
patient care device. Education is important for
you and me, But so is patient understanding you
see, Because Patient Safety is our primary
goal, It keeps patients well and it drives our
Soul. Annabel Hromas Quality Specialist
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MDRO Components

• Patient Education online easy accessible
• MRSA C. Difficle VRE
• Documentation in electronic record
• Staff Education
• Monthly MDRO Tips/ 2010
• Net learning 2011
• Quarterly Risk Assessment of MDRO by unit
• Prevention Strategies
• Weekly Isolation Audits for each unit
• MDRO Flagging All systems

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MDRO EducationPatient Education

• Nurse Resources
• Easily Accessible
• English and Spanish

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MDRO Patient Education
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Staff Education (MDRO)Measurement Tool Net
Learning
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Quarterly MDRO Risk Assessment by Unit
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Weekly Audit Tool
Measurement tool of Patient Education on Isolation
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DirectorsIsolation Audit Outcomes Report
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Flagging
MRSA Removal Pt last MRSA culture must be 6
months or gt / original culture site Clean and a
neg nasal culture. Only Infection Prevention
can remove a MRSA flag.
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Thing 4 Prevention of Central Line Infection
NPSG 07.04.01
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Components

• CL Policy with cleaning of Hub
• Pt Ed/ Documentation
• Staff Education
• Central Line Insertion Cart with supplies
• Central Line Checklist
• Central Line Bundle for Insertion
• Hand Hygiene
• Maximal Barrier Precautions Upon Insertion
• Chlorahexidine (CHG) Skin Antisepsis
• Optimal Catheter Site Selection, with avoidance
  of the
• Femoral Vein for Central Venous Access in Adult
  Patients
• Daily Review of Line Necessity with Prompt
  Removal of unnecessary Lines
• Risk Assessment and Outcome

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Central Line Check List
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Central LineOutcome Graph
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Scrub the Hub Staff CL Education and
Implemented in Protocol
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Central LinePatient Education Documentation
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Thing 5
Surgical Site Infection NPSG 07.04.01
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Components

• SSI Policies for Prevention
• Preprinted Orders
• Patient Education
• Making Surgery Safer given
• in Pre Admit
• Document on Patient Education on Universal Time
  out sheet
• Staff Education
• OR competency on hire and annually
• Monthly SSI prevention Ed
• Quarterly Risk Assessment on Targeted SSI

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Pre OperativeAntibiotic Order Set
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Surgical Patient Education
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Patient EducationDocumentation
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SCIP Element 9
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Staff Education (SSI)
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Surgical Site InfectionOutcomes
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DashBoard SSI Outcomes
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NPSG SUMMARY
So in summary you will find It will be best to
keep in mind Number Seven is infection
prevention You can do it without
apprehension Remember these symbols they are
quite easy Although the rhymes are somewhat
cheesy These Four Things will prevent
disaster Making Patient Safety at BSA the
Master When Joint Commission comes through our
door We will be prepared and receive a perfect
score Charlotte Wheeler
1. 3. 4. 5.
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Questions