NSQHS Standard 3: How are we going?

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1 NSQHS Standard 3: How are we going? Sue Greig RN, MN (Inf Cont) Syd Uni, CICP Adjunct Lecturer, Griffith University Senior Project Officer, National HAI Prevention Program

2 The NSQHS Standards Standard 1 Governance for Safety and Quality in Health Service Organisations Standard 2 Partnering with Consumers Standard 10 Preventing Falls and Harm from Falls Standard 9 Recognising and Responding to Clinical Deterioration in Acute Health Care Standard 8 Preventing and Managing Pressure Injuries Large numbers of patients effected Known gap between current situation and best practice outcomes Evidence based, achievable improvement strategies exist Standard 3 Healthcare Associated Infections Standard 4 Medication Safety Standard 5 Patient Identification and Procedure Matching Standard 7 Blood and Blood Products Standard 6 Clinical Handover

3 Why have a Standard about preventing infection? preventable common increase morbidity, mortality, pain & suffering cost to patients, hospital staff, health system no single solution range of strategies

4 Where are we now? The current NSQHS Standards will be in place until Australian Guidelines for the Prevention and Control of Infection in Healthcare were released in 2010, currently being revised with completion anticipated 2017/18 GENCA Guidelines Infection Control in Endoscopy revised 2010/11 The requirement for organisations to have responded to AS/NZS 4187:2014 is December 2016 There is variation in the compliance requirements between office practice settings (AS/NZS 4815:2006) and health service organisations (AS/NZS 4187:2014) There is an opportunity for review of AS/NZS 4187:2014 to extend the scope to address the variation between the Australian Standards Economies of scale and expectations Sterilising services are being stretched by service delivery, supply and demand issues Governance could be improved to address risk in endoscopy reprocessing and sterilising services

5 In summary Current Australian IC Guidelines /18 Current NSQHS Standards 2013 until 2017/18 Revised NSQHS Standards implement between 2017/19 ASNZS 4187:2014 HSOs implement the requirements within 2yrs December 2016 ASNZS 4815:2006 inconsistent with other reprocessing requirements Legislation relating to IC Standards and practitioners 2010 but inconsistent nationally State and territory IC guidelines and policy no consistency in review times Professional organisations no consistency in review times

6 However, all it not lost The Commission has released an Advisory Notice (A16/03) for health service organisations and surveying organisations too outline what is required by the organisation to demonstrate they have met the intent of the actions on reprocessing reusable medical devices in the NSQHS Standards. This will include: Completion of a gap analysis and document findings of the organisations current levels of compliance Have a detailed implementation plan with specified timeframes for full implementation over 5 year period from December 2016 Implementation of the plan and demonstration of progress Accreditation agencies will assess: Progress on implementation at each accreditation assessment Rate met only in HSOs that demonstrate progress towards full implementation of their plan

7 Why is governance important for sterilising services? Reprocessing of RMDs is part of the organisation s business is expensive requires forward planning for both services and resources is a highly specialised service has risks that are unique in the organisation and for patients Under current structures in many hospitals sterilising services often report through operating theatre managers - their largest customer!

8 Governance and sterilising services Where does governance responsibility sit in your organisation? Policies, procedures and protocols to reflect the position of the organisation and how it responds to the risks identified Issues to be considered at organisational/network/jurisdictional level to response to risk management issues include: Contracts for services Loan sets, consignment stock and special items Surgeons preferences Specialised services e.g. endoscopy/bronchoscopy/interventional radiology/opd clinics Storage Approvals processes for new stock or equipment Wet and dry biofilm management Maintenance, upgrade, life spans, validation and quality monitoring systems External influences water quality, waste, AS/NZS, NSQHS Standards, international inconsistencies Work relationship with key stakeholders Executive, managers, OR staff, surgeons, clinical staff, technicians, suppliers, contracted services Training pre-requisite requirements, ongoing, access and availability

9 Criteria for Standard 3 Governance and systems for IPC and surveillance Strategies for IPC Managing patients with infections or colonisation AMS Cleaning, disinfection or sterilisation Communicating with patients and carers

10 Cleaning, disinfection and sterilisation Links between Standard 1 and Standard 3 as well as within Standard 3 with criteria Governance and Cleaning, Disinfection and Sterilisation 3.15 Environmental cleaning 3.16 Reprocessing reusable medical equipment, instruments and devices 3.17 Identification of patients on whom reusable medical devices have been used (traceability/tracking) 3.18 Competency based training for those who are involved in decontamination of reusable medical devices

11 Current NSQHS action Reprocessing reusable medical equipment, instruments and devices in accord with relevant national or international standards and manufacturer instructions. Draft revised action Where reusable equipment, instruments and devices are used, the health service organisation has: a) processes for reprocessing that are consistent with relevant national and international standards and in conjunction with manufacturers instructions b) a traceability process for critical and semi-critical equipment, instruments and devices that is capable of identifying: the patient the procedure the reusable equipment, instruments and devices that were used for that procedure Why? Minimise risks of infection to patients and the workforce in the organisation How? Governance awareness of compliance requirements, scope of services, capital expenditure, organisation-wide risk assessment and management plan, currency of policy, procedures and/or protocols that allow measurement of quality improvement activities

12 When looking at risk consider: What reprocessing the organisation or service needs to consider based on services provided? Do the current services meet compliance requirements? Are there policies, procedures and protocols to cover the scope of services provided? Are these incorporated into the governance structures of the organisation? Is there a management plan in place to address reprocessing issues? How will the organisation or service achieve this equipment, utilities, training and consumables? Are there equipment and logistics expenses to be considered to improve or maintain services in line with required standards? Additional options to consider - Outsourcing to external providers Single use items Loan sets/ special equipment Purchase of sterile stock

13 What other evidence to consider Product selection and compatibility with reprocessing available Equipment and environmental maintenance that includes upgrade, space, schedules, fault and variance reporting, external services Quality control systems that include document control, audit and compliance reports, microbiological and chemical test results Incident reports Training provided to those responsible for undertaking reprocessing Education and training for the introduction of new products and equipment

14 Water quality in Australia Where does your water come from? How is it filtered or treated? Is there a maintenance program for the filtration/treatment process? Microbiological, quality monitoring and sampling process? What do you do if you get an unsatisfactory result? Cost to provide suitable water to reprocess reusable medical devices? Source: 7 National News 19 May 2016

15 Current NSQHS action Implementing systems to enable identification of patients on whom the reusable medical devices have been used Having a traceability system to identify patients and procedures where sterile reusable medial instruments and devices is in place Draft revised action Where reusable equipment, instruments and devices are used, the health service organisation has: a) processes for reprocessing that are consistent with relevant national and international standards and in conjunction with manufacturers instructions b) a traceability process for critical and semicritical equipment, instruments and devices that is capable of identifying: the patient the procedure the reusable equipment, instruments and devices that were used for that procedure Why? Minimise risk to patients of contracting infection from reusable medical devices If there is a reprocessing failure or an infection risk then the equipment, instruments and patients can all be identified. How? Look at what current systems are and can they be improved?

16 What are the risks relating to traceability or tracking? Can the organisation or service identify critical and semi-critical reusable medical devices used? Can the organisation or service identify on which patient these items were used? Can the organisation or service do this retrospectively?

17 Current NSQHS action Draft revised action Competency based training for those who are involved in decontamination of reusable medical devices. To be addressed within Governance actions 1.19 and 1.20 Why? Appropriate and correct decontamination is critical to reprocessing of reusable medical devices to reduce risk of infection How? As part of the organisations training and competency assessment processes, provision of appropriate training to those who undertake decontamination and assessing competence of the relevant workforce.

18 What are some of the risks to consider: Look at where decontamination occurs and who undertakes the task? Have those staff been trained? How and by what method? Is the training current and in-line with best practice? Is the training consistent? Do they have the resources to safely undertake decontamination? Is competency assessed and if so by whom/how?

19 The key points for the organisation or service to consider for cleaning, disinfection and sterilisation of critical and semi-critical reusable medical devices are: Risk assess the services required and provided in the setting Governance systems in the organisation or service to respond to identified risks Identification and planning for current and future needs to sustain reprocessing services and/or scope of services provided Have current policies, procedures and protocols to cover the scope of services that have been developed or reviewed by people with content knowledge Have a system to identify patients on whom critical and semi-critical reusable medical devices have been used (traceability or tracking) Identify and then provide or access competency based training for those who are involved in decontamination of reusable medical devices.

20 How times have changed Husbands are like Kleenex soft, strong and dependable Ball of Fire 1985 Husbands are like Kleenex soft, strong and disposable Clue Sterilising services are an area that has experienced significant change in the last 30 years with the technology required, training required and scope of services demanded and offered.