A Crosswalk Between The Regulatory Alphabet Soup

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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

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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

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Program Comparisons

• CMS COPs have 2 standards
• 1st affects organization and policies
• 2nd 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

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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

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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?

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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?

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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?

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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?

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Compare and Contrast (cont.)

• CoP 482.42 cont.
• The hospitals IC program must be integrated into
  its hospital-wide QAPI program.
• PI.1.10 Collects data to monitor performance
• 16. IC surveillance and reporting

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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

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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

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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

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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

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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

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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?

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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

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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

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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

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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?

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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

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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

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

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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!

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IC and EC overlap

• Construction and ICRAs
• Facility cleanliness and maintenance
• Hand hygiene
• Sharps
• Spills
• Sterilization and disinfection
• Sink placement
• Utilities Air and water
• Equipment Management biomed, SPD

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JCAHO take home messages

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

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CMS take home message

• Survey request list
• Organizational chart
• IC manual
• IC meeting minutes
• Log of infections/communicable diseases
• Policies and procedures
• Reporting and monitoring systems
• Surveillance plan
• Emergency preparedness documentation

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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

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Thank You and Questions?