Part II Quality improvement in long-term care: Partnership of infection prevention and environmental services

Transcription

1 Part II Quality improvement in long-term care: Partnership of infection prevention and environmental services Using the Centers for Medicare and Medicaid Services (CMS) Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) Deb Patterson Burdsall PhD, RN-BC, CIC, FAPIC 1

2 Disclosures The following speaker discloses no actual or potential conflicts of interest in relation to this program/presentation: Deb Patterson Burdsall PhD, RN-BC, CIC, FAPIC The following planning staff report no actual or potential conflicts of interest in relation to this program/presentation: Carol McLay, DrPH, MPH, RN, CIC Charu Malik Colin Richardson Kristen Henry Learning Objectives Understand how answers to questions from Part I relate to the current environmental cleaning and disinfecting processes Learn about the collaborative approach between infection prevention and environmental services for quality improvement Understand how the CMS Quality Assurance Performance Improvement (QAPI) toolkit can help Learn how to implement the QAPI-PIP model 2

3 Conclusions from Part I Environmental cleaning and disinfecting require explicit knowledge and training and dedicated staff The facility Infection Preventionist (IP) has responsibility for the EVS program as it relates to infection prevention and control There are manufacturers, distributors and service companies with healthcare EVS expertise Break the Chain of Infection Image: Pickit Free Images 6 3

4 Question: Who Is Listening Today? 1. Front-line staff (nurses, CNAs, housekeeping/environmental services (EVS) staff) 2. Directors and Assistant Directors of Nursing who are also Infection Preventionists 3. Infection Preventionists with no other job responsibilities 4. EVS Directors, Managers, Supervisors 5. Administrators, VPs of services 6. Owners, board members, CEOs, CFOs Addressing questions from Webinar Part I APIC Certificate of Training in Infection Prevention in the Long-Term Care Setting? Bleach solutions? Johnny mops? Effective and low toxicity cleaning and disinfecting? 4

5 APIC Certificate of Training in Infection Prevention in the Long-Term Care Setting This course teaches the basics of infection prevention in the long-term care setting, including: Infection Prevention and Control (IPCP) program and risk assessment development Facility-wide assessment and Quality Assurance and Performance Improvement (QAPI) program as it relates to the IPCP QAPI infection prevention Performance Improvement Projects (PIP) Antibiotic stewardship LTC infection surveillance, using and reporting data Multi drug-resistant and extensively drug-resistant organisms (MDRO and XDRO) National Healthcare Safety Network (NHSN) reporting Standard and transmission-based precautions An online version of this class is scheduled to be available during the last quarter of APIC will provide both face to face or online options for completing the course before November 28, 2019 Mixing Bleach Solutions and Human Factors Mixing bleach is difficult Lots of room for human error Science Photo 5.25% to 6.0% bleach considered hazardous: 2012 OSHA Hazard Communication Standard Category 1 health hazard and corrosive Requires ventilation, gowns/aprons, gloves, and eye protection 5

6 Mixing of Chlorine Bleach for Disinfection 1:1000 Bleach Solution (approx. 50 ppm) 1 cc (1/4 teaspoon) bleach cc (4 cups) of water IDPH Food Safety 1:500 Bleach Solution (approx. 100 ppm) 1 cc (1/4 teaspoon) bleach cc (2 cups) of water (Smooth Hard Surfaces: Intermediate disinfection) 1:100 Bleach Solution (approx. 500 ppm) 5 cc (1 teaspoon) bleach cc ( 2 cups) of water Nonporous surfaces after a small spill (<10cc) 1:50 Bleach Solution (approx ppm) 20 cc (4 teaspoons) bleach cc (4 cups) of water Concentrated spills of microorganisms 1:10 Bleach Solution (approx ppm) 62 cc (1/4 cup) bleach cc ( 2 ¼ cups) of water Endemic Clostridium difficile or outbreaks **(Concentration found in bleach/detergent wipes) Johnny Mops Can become a fomite/reservoir (spread organisms from room to room) Are hard to clean and disinfect (soft surface bristles) Consider dedicating to isolation rooms Make routine replacements Consider different methods (e.g. wipes, toilet wands with disposable ends) 6

7 Cleaning and Disinfecting Products Do you have examples of products with low toxicity but still effective to kill broad range of microbes with low contact time? Advanced hydrogen peroxide products Peracetic acid products Citric acid with silver ion products Newer bleach formulations Ultraviolet CDC: EVS Recommendations Joint infection prevention / EVS team effort Base on Facility Assessment Responsibilities for cleaning high touch surfaces (e.g., nursing, activities, culinary surfaces) must be clearly defined Training and competency must be maintained Quality assessment and assurance (QAA) / quality assurance and performance improvement (QAPI) processes should be ongoing Guh & Carling, Link accessed 5/22/17 7

8 Source: Link accessed 5/22/17 Centers for Medicare and Medicaid Services (CMS) Mega Rule Reform of Requirements Phase I November 28, 2016 Basic Infection Prevention and Control Program (IPCP) Phase II November 28, 2017 IPCP linked to Facility Assessment Antibiotic Stewardship Program Phase III November 28, 2019 Trained Infection Preventionist (IP) IP participation in Quality Assurance 8

9 Facility-wide Assessment by November 28, 2017 Determine necessary resources to competently care for residents All hazards approach Review As necessary At least annually At any significant change Source: Federal Register Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities Final Rule: 10/4/16. Link accessed 5/22/17 Image: Pixabay_P. Marco 17 Residents The facility s resident population The care required for resident population: Types of diseases, conditions, physical and cognitive disabilities Overall acuity Other pertinent facts that are present within that population Ethnic, cultural or religious factors Pixabay Pixabay 18 9

10 Personnel Staff competencies for level and types of care needed Ethnic, cultural, or religious factors All personnel, including managers, facility staff, volunteers, and contract employees 19 Infection Prevention Training and Competency Goal: staff comply with infection control practices Initial and ongoing infection control education when policies and procedures are revised when there is a special circumstance (e.g. outbreak) SciencePhoto When there is required modification or replacement of current practices Link Accessed 5/22/

11 Training and Competency Specific infection control training with follow-up competency evaluations Stock Unlimited Monitoring Environmental cleaning and disinfecting ARE infection prevention and control activities Link Accessed 5/22/17 21 CMS and CDC focus on nursing homes Residents frequently colonized with multi drug-resistant organisms (MDRO) (e.g. MRSA, Clostridium difficile, VRE, CRE, KPC) 30%-50% of frail, elderly long-term care residents with asymptomatic bacteriuria Skilled nursing = reservoir for MDRO Pixabay Poor inter-facility and intra-facility communication Infection related hospitalizations and deaths among nursing home residents and patients Source: CDC: Link accessed 5/22/17 11

12 QAPI Element 1: Design and Scope Maintain ongoing and comprehensive written plans (evidence-based goals) Include full range of services Address all systems of care and management practices Emphasize safety and high quality care Emphasize autonomy and choice Source: 12

13 QAPI Element 2: Governance and Leadership Foster culture where QAPI is a priority Seek input from entire Interdisciplinary Team (IDT) Assure adequate resources for QAPI safety, quality, rights, choice and respect Balance resident rights and safety Make person(s) accountable for QAPI: Leadership and facility-wide training Source: QAPI Element 3: Feedback, Data Systems & Monitoring Monitor care and services Actively incorporate input from IDT Monitor processes and outcomes Review findings against benchmarks Track, investigate and monitor adverse events Develop action plans to prevent recurrences Source: 13

14 QAPI Element 4: Performance Improvement Projects (PIPs) Concentrate efforts on particular problem(s) Gather information systematically Clarify issues or problems Intervene to improve Source: QAPI Element 5: Systematic Analysis & Systemic Action Analyze and understand the problem, causes and implications of change Identify how problems are occurring with consistent processes (e.g. root cause analysis) Take systemic actions look across all involved systems Develop policies and procedures and demonstrate proficiency Promote sustained improvement to prevent future events Source: 14

15 Quality Assessment and Assurance (QAA) November 28, 2016 Management process Ongoing, multi-level All managerial, administrative, clinical and environmental services Performance of outside (contracted or arranged) providers and suppliers of care and services Purpose is continuous evaluation of facility systems Source: CMS Mega Rule State Operations Manual 3/6/2017 Quality Assessment and Assurance (QAA) Continuous evaluation of facility systems Keep systems functioning consistently Maintain current practice standards Prevent deviation from care processes Identify and correct issues and concerns ( inappropriate care processes ) 5.17 Source: CMS Mega Rule State Operations Manual 3/6/

16 Question (yes/no) 1. I am included in the product-selection process 2. I am involved with training staff to use a new product 3. The IP is required to assist with EVS monitoring 4. The IP is required to be a part of the QAPI process 5. I know what a GPO is (before this webinar!) Performance Improvement Project (PIP) Concentrate on a particular problem in one area of the facility or facility wide Gather information systematically Use team approach to identify the cause of a problem Fix problems that are important and meaningful for the specific type and scope of services Source: Appendix B QAPI Definitions: Certification/QAPI/Downloads/QAPIAtaGlance.pdf Link accessed 5/22/17 16

17 Sample Case Study Why is a QAPI PIP needed? Your facility assessment reveals that increasing numbers of patients and residents are colonized with multi drugresistant organisms (MDRO) such as carbapenemresistant Enterobacteriaceae (CRE) IP does not work with EVS to select cleaning/disinfecting products Product selection is a corporate decision Cleaning and disinfecting is not routinely monitored 17

18 The Business Case Combine what you have to do with what you need to do! Group Purchasing Organizations (GPO) Interdisciplinary Purchasing Committees QAPI Performance Improvement Project (PIP) PIP Team = Interdisciplinary Purchasing Committees PIP Team Form PIP team for product selection and system change PIP team consists of those who use, purchase and pay for the cleaning disinfecting chemicals Front-line personnel Managers and supervisors Materials Management and Purchasing CEO, CFO, Owners may need to be part of the team 18

19 Root Cause Analysis Chemicals are purchased based on cost rather than on efficacy/effectiveness and ease of use No consistent process to ensure cleaning and disinfecting chemicals are at point of care No competency-based training No routine monitoring of cleaning/disinfecting Punitive approach Emphasis is working quickly Root Cause Analysis continued No permanent EVS supervisors The last supervisor left 6 months ago The corporate supervisor rounds once a month Supply company for cleaning and disinfecting chemicals specializes in janitorial and food service No healthcare expertise or support The disinfectants (when available) require a 10 minute wet contact time The EVS housekeepers speak very little English. The corporate supervisor does not speak Spanish, Polish or Vietnamese 19

20 PIP Team Observations First Floor Second Floor Third Floor Photos: 2017 Mommarazzi Images Group Purchasing Organization (GPO) GPO saves a facility time and money Negotiates lower prices for products (estimate 10-15% off purchase costs) Healthcare providers form committee for product selection Once products are selected, use GPO negotiated price Source: Healthcare Supply Chain Association (HSCA) Link accessed 5/22/17 20

21 Cleaning and Disinfecting Products Select products with the assistance of the PIP Team, GPO representation and company with healthcare expertise Shortest contact time to kill the most organisms with lowest human toxicity Advanced hydrogen peroxide products Peracetic acid products Citric acid with silver ion products Newer bleach formulations Healthcare EVS companies can provide support and training as part of the contract Pilot Pilot the environmental services program on selected unit(s) or facilities PIP team collect data on environmental cleaning, and staff and patient/resident response Potentially compare other infection prevention indicators (e.g. readmission rates, infection rates) Modify and expand Document and take credit for a QAPI PIP!! 21

22 Thank You! Questions? Deb Burdsall 22