The Joint CommissionThe Joint CommissionNPSGNPSG

NPSG # 7Compliance The Dr. Seuss Way

Annette Moore RN CICCharlotte Wheeler RN BSN CIC

Baptist St. Anthony’s Health SystemBaptist St. Anthony’s Health SystemAmarillo TexasAmarillo Texas

Our HouseOur House

451 Bed Acute Care Hospital 451 Bed Acute Care Hospital 48 Critical care beds48 Critical care beds 20 Bed Level 1 NICU unit20 Bed Level 1 NICU unit 15,000 surgical procedures/year15,000 surgical procedures/year Free Standing Cancer CenterFree Standing Cancer Center 2 Ambulatory Surgery Centers2 Ambulatory Surgery Centers 2 Ambulatory Care Clinics2 Ambulatory Care Clinics Inpatient RehabInpatient Rehab Target Surveillance withTarget Surveillance with

2 AWESOME FTE = 1 FTE per 225 bed2 AWESOME FTE = 1 FTE per 225 bed

The Journey BeginsThe Journey Begins2008 TJC unveils their 2009 NPSG 2008 TJC unveils their 2009 NPSG

with timeline for implementationwith timeline for implementationOur Response……. Our Response……. Leadership assigns Committees for Leadership assigns Committees for

all NPSGall NPSGBrainstorming for Compliance with Brainstorming for Compliance with

NPSG includes Education Strategy: NPSG includes Education Strategy: Education Strategy ----: Education Strategy ----:

Think out of the box Think out of the box EXTREME EXTREME EDUCATIONEDUCATION

The ChallengeThe ChallengeEducating Out of the BoxEducating 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”

Playing/Fun not just for KidsPlaying/Fun not just for Kids It’s the doorway to learningIt’s the doorway to learning Our mind is more alert and can learn faster and without barriersOur mind is more alert and can learn faster and without barriers Connects us to others provides a relaxed environment and works Connects us to others provides a relaxed environment and works

as team buildingas team building Benefits of Playing and Fun at workBenefits of Playing and Fun at work

keeps you functional when under stress keeps you functional when under stress refreshes your mind and body refreshes your mind and body encourages teamwork encourages teamwork helps you see problems in new ways helps you see problems in new ways triggers creativity and innovation triggers creativity and innovation increases energy and prevents burnout increases energy and prevents burnout

"People rarely succeed unless they have fun in what they "People rarely succeed unless they have fun in what they are doing." are doing."

Dale CarnegieDale Carnegie

http://www.helpguide.org/life/creative_play_fun_games.htmhttp://www.helpguide.org/life/creative_play_fun_games.htm

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

TJC 2009 Time LineTJC 2009 Time LineMDRO, CL and SSIMDRO, CL and SSI

April 1April 1stst – Leadership Assigns – Leadership Assigns Responsibility and oversight for Responsibility and oversight for compliancecompliance

July 1July 1st st - Implementation Work plan in - Implementation Work plan in Place including resources neededPlace including resources needed

October 1October 1stst - Pilot testing in at least one - Pilot testing in at least one clinical unitclinical unit

January 1January 1stst 2010 – Elements of 2010 – Elements of performance fully implemented across the performance fully implemented across the hospital hospital

Initial AssessmentInitial Assessment NPSG #7 NPSG #7

Assessment of processes in place meeting Assessment of processes in place meeting NPSG requirementNPSG requirement : :

Hand Hygiene Program and Audits in place Hand Hygiene Program and Audits in place ( less emphasis in 2010 ( observation)( less emphasis in 2010 ( observation)

Sentinel Event (deleted in 2010) Process in placeSentinel Event (deleted in 2010) Process in place MDRO Flagging Process in placeMDRO Flagging Process in place Central line Protocol/ IHI Bundle Process in placeCentral line Protocol/ IHI Bundle Process in place SCIP Protocol/Bundles Process in PlaceSCIP Protocol/Bundles Process in Place

First Glance: We’re in GREAT SHAPEFirst Glance: We’re in GREAT SHAPE

On a Closer LookOn a Closer LookMDRO MDRO

No Patient education implemented or No Patient education implemented or documentation processdocumentation process

Measurement tool?Measurement tool?

No formal education for staffNo formal education for staffMeasurement tool?Measurement tool?

Isolation compliance hit and missIsolation compliance hit and missMeasurement toolMeasurement tool

Venue for presenting quarterly MDRO Venue for presenting quarterly MDRO surveillancesurveillance

MDRO Flagging only on one system, not MDRO Flagging only on one system, not the system nurses use oftenthe system nurses use often

Closer Look :Closer Look :Central Lines Prevention ElementCentral Lines Prevention Element

Only receiving 30 checklist/month from Only receiving 30 checklist/month from 150/month procedures150/month procedures

Central line carts on the floor/ checklist Central line carts on the floor/ checklist not usednot used

OR not using checklistOR not using checklistNo patient education or documentation No patient education or documentation

processprocessProtocol does not include scrub the hubProtocol does not include scrub the hubNo formal education for staffNo formal education for staff

The Closer LookThe Closer LookSurgical Site Infection PreventionSurgical Site Infection Prevention

Education to patient includes what to expect Education to patient includes what to expect in surgery /No education/documentation for in surgery /No education/documentation for patient on prevention measures for SSI patient on prevention measures for SSI preventionprevention

Measurement toolMeasurement toolNo formal education for staff except in ORNo formal education for staff except in OR

Measurement toolMeasurement tool

The NPSG #7 Organizational The NPSG #7 Organizational TeamTeam

Met BiWeekly April - Met BiWeekly April - JulyJuly NursingNursing Critical CareCritical Care OROR Special ProceduresSpecial Procedures Documentation TeamDocumentation Team Case ManagementCase Management Quality ImprovementQuality ImprovementAll Responsible for taking 1 element of

NPSG using The Cat in the Hat as a formatResulting in a Fun Rhyme for NPSG

BSA NPSG Comic BookBSA NPSG Comic Book

NPSG NPSG The Comic Book and ToolsThe Comic Book and Tools

July 1July 1stst – NPSG Comic Book – NPSG Comic Book Online for staff accessOnline for staff access

Dec 31Dec 31stst – Deadline complete – Deadline complete education and post testeducation and post test

2010 Jan 12010 Jan 1st st – Compliance – Compliance AuditsAudits

2010 Jan 12010 Jan 1stst NPSG 7 Monthly NPSG 7 Monthly EducationEducation

NPSG # 7 Education starts in NPSG # 7 Education starts in New Nurse OrientationNew Nurse Orientation

Unit Education and Unit Education and bookmarksbookmarks

Sample of all NPSG ComicBook on PresentationTable

Staff EducationStaff Education Plan A : Housewide Education Plan A : Housewide Education

during Flu Vaccine during Flu Vaccine AdministrationAdministration Budget cuts and Flu ShortageBudget cuts and Flu Shortage

Plan B: Monthly Snippet Plan B: Monthly Snippet EducationEducation MDRO, Cline, SSIMDRO, Cline, SSI

IP develops and sends monthlyIP develops and sends monthly One Page InformationOne Page Information

Director/Educator responsible for Director/Educator responsible for staff education on unitstaff education on unit

Information kept on Education Information kept on Education Board/30 daysBoard/30 days

#7 NPSG Notebook available on #7 NPSG Notebook available on floor and onlinefloor and online

Measurement for Staff EducationMeasurement for Staff Education– – Net learning Post TestNet learning Post Test

Bookmark, comic NPSG 7 to staff Bookmark, comic NPSG 7 to staff in staff meetingsin staff meetings

Meet The Cat Meet The Cat BSA Infection PreventionistBSA Infection Preventionist

Infection Infection PreventionPreventionNPSG #7NPSG #7

THING 1 THING 1 Hand HygieneHand Hygiene NPSG 07.01 NPSG 07.01

Hand Hygiene ComponentsHand Hygiene ComponentsHousewide Goal 95% or >Housewide Goal 95% or >

BSA Hand Hygiene ProgramBSA Hand Hygiene Program “ “ Gel to Excel ”Gel to Excel ” Program based upon CDC guidelinesProgram based upon CDC guidelines

BSA Gold Standard: BSA Gold Standard: Hand Hygiene every time you enter pt roomHand Hygiene every time you enter pt room

Patient EducationPatient Education It’s Ok to AskIt’s Ok to Ask

Hand Hygiene Audits monthlyHand Hygiene Audits monthly Each Clinical Dept Director responsible to submit a minimum of Each Clinical Dept Director responsible to submit a minimum of

10/month10/month Outcome Audits provided monthly to each unitOutcome Audits provided monthly to each unit Nursing and Ancillary Directors Performance Evaluation depends Nursing and Ancillary Directors Performance Evaluation depends

upon their units HH rateupon their units HH rate Secret Shoppers and Unit ObservationSecret Shoppers and Unit Observation

To keep the balance and to prevent Directors skewed To keep the balance and to prevent Directors skewed perceptionsperceptions

Patient EducationPatient EducationIt’s Ok to AskIt’s Ok to Ask

Hand Hygiene Audit toolHand Hygiene Audit tool

Hand Hygiene OutcomesHand Hygiene Outcomes

Thing 3 Thing 3 Multiple Drug Resistant OrganismsMultiple Drug Resistant Organisms

NPSG 07.03.01 NPSG 07.03.01

As Infection Control we must prevent,An HAI in any event

MDRO’s 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 HromasQuality Specialist

MDRO ComponentsMDRO Components

Patient Education – online easy Patient Education – online easy accessibleaccessibleMRSA C. Difficle VREMRSA C. Difficle VREDocumentation in electronic recordDocumentation in electronic record

Staff EducationStaff EducationMonthly MDRO Tips/ 2010Monthly MDRO Tips/ 2010Net learning 2011Net learning 2011Quarterly Risk Assessment of MDRO by unitQuarterly Risk Assessment of MDRO by unit

Prevention StrategiesPrevention StrategiesWeekly Isolation Audits for each unitWeekly Isolation Audits for each unitMDRO Flagging – All systemsMDRO Flagging – All systems

MDRO EducationMDRO EducationPatient EducationPatient Education

• Nurse Resources • Easily Accessible• English and Spanish

MDRO Patient EducationMDRO Patient Education

Staff Education (MDRO)Staff Education (MDRO)Measurement Tool – Net Measurement Tool – Net

LearningLearning

Quarterly MDRO Risk Quarterly MDRO Risk AssessmentAssessment

by Unit by Unit

Weekly Audit Tool

Measurement tool of Patient Education on Isolation

DirectorsDirectorsIsolation Audit Outcomes ReportIsolation Audit Outcomes Report

FlaggingFlagging

MRSA Removal: Pt last + MRSA culture must be 6 months or > / original culture site Clean and a neg nasal culture. Only Infection Prevention can remove a MRSA flag.

Thing 4Thing 4 Prevention of Central Line Infection Prevention of Central Line Infection

NPSG 07.04.01 NPSG 07.04.01

ComponentsComponents

• CL Policy with cleaning of HubCL Policy with cleaning of Hub• Pt Ed/ DocumentationPt Ed/ Documentation• Staff EducationStaff Education Central Line Insertion Cart with suppliesCentral Line Insertion Cart with supplies Central Line Checklist Central Line Checklist Central Line Bundle for InsertionCentral Line Bundle for Insertion

Hand Hygiene Hand Hygiene Maximal Barrier Precautions Upon InsertionMaximal Barrier Precautions Upon Insertion Chlorahexidine (CHG) Skin AntisepsisChlorahexidine (CHG) Skin Antisepsis Optimal Catheter Site Selection, with avoidance Optimal Catheter Site Selection, with avoidance

of theof the Femoral Vein for Central Venous Access in Adult Femoral Vein for Central Venous Access in Adult

PatientsPatients Daily Review of Line Necessity with Prompt Daily Review of Line Necessity with Prompt

Removal of unnecessary LinesRemoval of unnecessary Lines Risk Assessment and Outcome Risk Assessment and Outcome

Central Line Check ListCentral Line Check List

Central LineCentral LineOutcome GraphOutcome Graph

Scrub the Hub Staff CL Education Scrub the Hub Staff CL Education and Implemented in Protocoland Implemented in Protocol

Central LineCentral LinePatient Education DocumentationPatient Education Documentation

Thing 5

Surgical Site Infection NPSG 07.04.01

ComponentsComponents

• SSI Policies for PreventionSSI Policies for Prevention• Preprinted OrdersPreprinted Orders

• Patient EducationPatient EducationMaking Surgery Safer Making Surgery Safer

givengiven

in Pre Admitin Pre AdmitDocument on Patient Document on Patient

Education on Universal Education on Universal Time out sheetTime out sheet

Staff Education:Staff Education: OR competency on hire and OR competency on hire and

annuallyannually Monthly SSI prevention EdMonthly SSI prevention Ed Quarterly Risk Assessment on Quarterly Risk Assessment on

Targeted SSITargeted SSI

Pre OperativePre OperativeAntibiotic Order SetAntibiotic Order Set

Surgical Patient EducationSurgical Patient Education

Patient EducationPatient EducationDocumentationDocumentation

SCIP Element # 9SCIP Element # 9

Staff Education (SSI)Staff Education (SSI)

Surgical Site InfectionSurgical Site InfectionOutcomesOutcomes

DashBoard DashBoard SSI OutcomesSSI Outcomes

NPSG SUMMARYNPSG SUMMARY

1.

3.

4.

5.

So in summary you will findIt will be best to keep in mind

Number Seven is infection preventionYou can do it without apprehension

Remember these symbols they are quite easyAlthough the rhymes are somewhat cheesy

These Four Things will prevent disasterMaking Patient Safety at BSA the Master

When Joint Commission comes through our doorWe will be prepared and receive a perfect score

Charlotte Wheeler

QuestionsQuestions