CANADIAN ASSOCIATION OF MEDICAL DEVICE REPROCESSING October 16 18, 2014 Winnipeg, MB

Transcription

1 Presentation Outline and Sterilization Standards Presented by Diana Sarakbi Accreditation Product Development Specialist Accreditation Canada 1. Accreditation Canada and the Qmentum accreditation program 2. Summary of the Infection Prevention and Control Standards Accreditation Revisions Canada 3. Overview of the and Sterilization Standards and 2013 Survey Results CAMDR Conference, Oct Accredited by Agréé par 2 What is accreditation? Process that organizations use to evaluate and improve the quality of their services Involves examining everyday activities and services against standards of excellence Strong focus on quality improvement, capacity building, and sustainability Accreditation Canada Incorporated in 1958 Not for profit Accreditation Canada International Accredited by ISQua (Feb 2014) 3 4 1

2 Accreditation Canada (cont d) Qmentum Clients from across the care continuum : Pre-hospital Hospital Community Care Over 1000 client organizations More than 500 peer surveyors Around 400 surveys per year Qmentum was introduced in 2008 Outcome-oriented Brings quality improvement into daily work 5 6 Accreditation Cycle Qmentum Standards POPULATIONS (used by regions) STANDARDS AREAS GOVERNANCE LEADERSHIP INFECTION PREVENTION AND CONTROL MEDICATION MANAGEMENT SERVICE EXCELLENCE Customized as required for specific sectors, services, and markets Population Health and Wellness SECTORS and SERVICES Acquired Brain Injury Medical Imaging Centres Ambulatory Care Medicine Ambulatory Systemic Cancer Therapy Mental Health Assisted Reproductive Technology Obstetrics Biomedical Laboratory Organ and Tissue Donation and Transplant Cancer Care and Oncology Perioperative and Invasive Procedures Case Management Point-of-Care Testing Child Welfare Primary Care Community Health Public Health Community-based Mental Health Rehabilitation Critical Care Remote/Isolated Health Developmental Disabilities and Sterilization Diagnostic Imaging Residential Homes for Seniors Emergency Department Spinal Cord Injury Emergency Medical Services Staffing Agencies Home Care and Home Support Substance Abuse and Problem Gambling Hospice Palliative and End of Life Telehealth Independent Medical Surgical/Facilities Transfusion Long-Term Care CUSTOM MARKETS Aboriginal Health Services Corrections Canada Provincial Corrections 7 8 2

3 Standards Development 1. Form a Standards Working Group 2. Complete Literature Review 3. Develop Standards 4. Evaluate Standards through National Consultation and Pilot Testing 5. Revise Standards based on Feedback 6. Prepare Standards for Release 9 10 Program Updates New Standards Sept 2014: Trauma Distinction Revisions Jan 2015: Client- and Family-Centred Care Common Service Content Leadership and Governance In Progress: Medical Transport Cancer Care/Radiotherapy Infection Prevention and Control Standards

4 IPC Standards Standards Working Group The IPC standards were first released with Qmentum in 2008 Revised for Jan 2014 with a standards working group Updates are applicable during on-site surveys one year after release Revisions ensure that standards reflect current research and continue to meet client needs Representation from clients, surveyors and the following key associations: 14 National Consultation National Consultation (cont d) The revised IPC standards were evaluated through the national consultation A survey where clients, surveyors and other stakeholders across Canada review and provide feedback on the standards Comments were compiled and reviewed with the standards working group

5 IPC Standards Revisions Language enhancements and addition of a glossary to improve clarity Re-structuring the standards to reflect the key steps for developing an effective IPC program 3. Evaluating the Impact of the IPC Program 1. Planning and Developing the IPC Program 2. Implementing the IPC Program Planning and Developing the IPC Program : Collaborative approach with key teams across the organization, including: Medical device reprocessing Environmental services Occupational health and safety Pharmacy Surgical care 2. Implementing the IPC Program : Having a multi-faceted approach to promoting IPC within the organization: Empowering staff to identify ways for increasing compliance with IPC practices Posting reminders throughout the organization Providing access to educational tools, e.g. CPSI Hand Hygiene e-learning, and the Clean Learning program for environmental services Ongoing feedback and improvements

6 2. Implementing the IPC Program (cont d) : 2. Implementing the IPC Program (cont d): Maintaining a clean and disinfected physical environment: Developing a comprehensive hand-hygiene strategy: Developing policies and procedures Assigning roles and responsibilities Cleaning and disinfecting the rooms of clients who are on additional precautions Staff training Providing access to hand-hygiene products Posting reminders about proper techniques for hand-washing and using alcohol-based hand rubs Implementing the IPC Program (cont d) : 3. Evaluating the IPC Program : Addressing IPC in the occupational health and safety program, including: Making ongoing improvements to the IPC program based on staff and client input, including: Immunization policy to screen and offer vaccinations to staff Using Personal Protective Equipment (PPE) Work restrictions for staff with transmissible diseases Handling bio-hazardous materials Processes for cleaning and disinfecting the physical environment Hand hygiene practices

7 IPC Standards References (examples) WHO Clean Care is Safer Care PHAC Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings CPSI Canada s Hand Hygiene Challenge: STOP! Clean Your Hands PIDAC Best Practices for Environmental Cleaning for Prevention and Control of Infections and Sterilization Standards and Sterilization Developed with CSA and released in 2008 Highlights the essential role of the Medical Device (MDR) department in patient safety Minor updates to align with IPC revisions, and CSA references in 2013 and Sterilization (cont d) Evaluates reprocessing activities that are completed inside the MDR To cover reprocessing activities completed outside the MDR, the following standards were updated with reprocessing content: Infection Prevention and Control Diagnostic Imaging Operating Rooms Ambulatory Care Obstetrics

8 and Sterilization (cont d) and Sterilization (cont d) Does the client have an MDR? CSA References Yes No and Sterilization Standards IPC Standards without reprocessing section IPC Standards with reprocessing section and Sterilization (cont d) and Sterilization (cont d) 1. Planning Services Department Design Physical Layout Education and Training 2. Complying with Best Practices Policies and Procedures OHS Records 3. Using Equipment Selection Installation Maintenance 4. Providing Services Preparation Cleaning and Disinfection Operating Equipment 5. Evaluating Activities Tracking Medical Devices Recalls 82 clients were evaluated with the and Sterilization standards in 2013 Majority were health systems and acute care services Overview of strengths and areas for improvement

9 and Sterilization (cont d) and Sterilization (cont d) Strengths: Areas for Improvement: 1. Planning Services 2. Complying with Best Practices 3. Using Equipment 4. Providing Services 5. Evaluating Activities 1. Planning Services Department Design Physical Layout Policies and Procedures OHS Selection Installation Preparation Cleaning and Disinfection Tracking Recalls Department Design Physical Layout Equipped hand hygiene facilities (e.g. faucets supplied with footoperated handles) Education and Training Records Maintenance Operating Equipment Education and Training Baseline and annual competency evaluations Next Steps Continuing to enhance the Qmentum standards based on stakeholder feedback and updates from the field Sharing results with partners and stakeholders across Canada to help improve the safety and quality of health care services for patients and their families Thank You! Questions? 36 9

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