Health Facility Compliance Patient Quality Care Unit Division of Regulatory Services Texas Department of State Health Services

 1864 agreement ◦ Agreement between CMS and the State ◦ DADS is the primary State agency ◦ DSHS draws moneys from DADS

 The federal government (HCFA/CMS) was told that they would HAVE to work with the States.

 Survey and Certification gets  ½ of one cent of every dollar

A very brief overview

 To promote patient safety ◦ Creating a safe environment ◦ Track and analyze  By tracking and analysis, we can all learn to avoid adverse events/sentinel events in the future

◦ Better care  Lower costs

 Surveys to evaluate compliance with 3 Conditions of Participation relating to reducing Hospital Acquired Conditions and readmissions: ◦ Quality Assessment Performance Improvement ◦ Infection Control ◦ Discharge Planning

INFECTION CONTROL TOOL The goal is to promote HAI prevention and patient safety in hospitals Patient Focused Tool is intended to be used by hospital surveyors to assess the minimum health and safety standards needed for hospitals to meet the Medicare Conditions of Participation for Infection Control The tool will be accessible for hospitals for self assessment of infection control compliance

QAPI- raw data, frequency of meetings, policies and procedures, outcomes, corrective action Credentialing of Infection Control Officer Medical record review Infection Control Officer Department Heads Patient/family interviews Direct care staff Physicians Ancillary staff

 Basic Infection Control  Delivery of Care  Isolation  Invasive Procedures  Sterile Processing  Environment

 The three key elements to determine compliance with any of the Conditions of Participation are:  Record Review  Interview, and  Observation

Infection Control  The goal is to promote HAI prevention and patient safety in hospitals  Patient Focused  The Survey Tool is intended to be used by hospital surveyors to assess the minimum health and safety standards needed for hospitals to meet the Medicare Conditions of Participation for Infection Control  This tool will be accessible for hospitals for self assessment of infection control compliance

To decide on compliance in the area of Infection Control, surveyors will conduct Record Reviews specifically looking at:  QAPI- raw data, frequency of meetings, policies and procedures, outcomes, corrective action  Credentialing of Infection Control Officer  Medical records

 Department Heads  Patient/family interviews  Infection Control Officer  Direct care staff  Physicians  Ancillary staff

And Observation of:  Basic Infection Control  Delivery of Care  Isolation  Invasive Procedures  Sterile Processing  Environment

 The following is a recent article stressing the importance of infection control and what can happen when basic control procedures are not utilized.

July12, 2012 — Repeated use of single-use medication vials has been linked to the transmission of life-threatening Staphylococcus aureus infection in 10 patients treated for pain in outpatient clinics in Arizona and Delaware, according to a new study from the US Centers for Disease Control and Prevention (CDC). Melissa Schaefer, MD, a medical officer in the CDC's Division of Healthcare Quality Promotion, and colleagues with the CDC and the Arizona Department of Health Services published their findings in the July 13 issue of the Morbidity and Mortality Weekly Report.published their findings Three patients initially treated at a single pain management clinic in Arizona were hospitalized from 9 to 41 days for S aureus infections after injection of a contrast solution from the same single-dose vial. A fourth patient who received an injection from the same vial was found deceased 6 days after the injection; invasive S aureus infection could not be ruled out. In Delaware, 7 patients with S aureus–based septic arthritis or bursitis were admitted to the hospital. All had received joint injections at the same outpatient clinic during the same recent 2-day period. An additional 3 patients who received injections at the clinic during this period required outpatient treatment for symptoms that suggested infection. The researchers found that reuse of a single-dose vial of bupivacaine among multiple patients was the only breach of safe practice at this clinic. According to the CDC, these outbreaks demonstrate the serious consequences that can result from misuse of single- dose vials. These vials typically do not contain preservatives and are intended for single-use injection to avoid risk for infection. The appropriate use of single-dose vials includes prompt use of the contents in a single patient during a single procedure and immediate disposal of the vial and any remaining contents, the CDC authors report. They add that difficulties in acquiring the appropriately sized medication vials, frequently a result of medication shortages, often lead to these safety breaches. "These outbreaks could be avoided if smaller medication vial sizes that better fit procedural needs were manufactured.” According to the CDC, 20 outbreaks associated with multiple-patient use of single-use or single-dose vials have been reported since "These investigations help remind health-care providers of infection prevention practices that are critical for patient safety," they note. "When outbreaks or clusters are identified, prompt notification of public health authorities is imperative to ensure that appropriate case-finding activities and infection control measures are implemented to prevent additional harm," they conclude.

 Communication  Organization  Teamwork and Cooperation  Support of the Medical Staff and Governing Body  Action

Assessing hospital compliance with the Condition of Participation for Quality Assessment & Performance Improvement (QAPI) Survey staff will utilize a specific tool

Information surveyors need to review for QAPI: Governing Body and Medical Executive By laws Hospital Rules and Regulations Minutes – Governing Body, Medical Executive, Quality Assurance Performance Improvement Casual Analysis or Root Cause Analysis policy and procedures QAPI program evaluation of contracted services

 QAPI plan for current and previous year  List of events (i.e. unusual occurrences, incidents, sentinel events or serious adverse events) for past 24 months  List of Casual Analysis or Root Cause Analysis  List of all QAPI policies and procedures

 Three quality indicator traces the facility is tracking will be chosen for review (i.e. discharge summary, hospital acquired infection)  Data for the past 12months will be requested for the three indicators chosen  Data is evaluated for how is collected and what is being done with this data

Casual Analysis or Root Cause Analysis  Three analysis will be chosen for review  When reviewing analysis, surveyors will be assessing: what happened, why it happened, what facility identify, if reported to proper agency and what steps facility implemented to prevent this from happening again.

If facility is working on a project (i.e. Certified Stroke Center, Certified Joint Replacement Center):  How is QAPI involved with the project.  What data is being collected  Is the project appropriate for services being provided

 New surveyor worksheet and survey process alone will NOT improve outcomes  Renewed focus on discharge planning with increased surveillance and enforcement  Hospitals will work to self-assess and improve their own processes  GOAL = Reduction of preventable readmissions

 Stay Connected  Communicate  Collaborate

 Make reducing Hospital Acquired Conditions and readmissions a priority for the governing body, hospital leadership, clinicians and all staff  Support clinicians and engage patients and families in making care safer  Learn from and share experiences with others