The Joint Commission NPSG NPSG # 7 Compliance The Dr. Seuss Way Annette Moore RN CIC Charlotte Wheeler RN BSN CIC

Baptist St. Anthony’s Health System Amarillo Texas

Our House 451 Bed Acute Care Hospital 451 Bed Acute Care Hospital 48 Critical care beds 48 Critical care beds 20 Bed Level 1 NICU unit 20 Bed Level 1 NICU unit 15,000 surgical procedures/year 15,000 surgical procedures/year Free Standing Cancer Center Free Standing Cancer Center 2 Ambulatory Surgery Centers 2 Ambulatory Surgery Centers 2 Ambulatory Care Clinics 2 Ambulatory Care Clinics Inpatient Rehab Inpatient Rehab Target Surveillance with Target Surveillance with 2 AWESOME FTE = 1 FTE per 225 bed

The Journey Begins 2008 TJC unveils their 2009 NPSG with timeline for implementation 2008 TJC unveils their 2009 NPSG with timeline for implementation Our Response……. Our Response……. Leadership assigns Committees for all NPSG Leadership assigns Committees for all NPSG Brainstorming for Compliance with NPSG includes Education Strategy: Brainstorming for Compliance with NPSG includes Education Strategy: Education Strategy ----: Education Strategy ----: Think out of the box EXTREME EDUCATION Think out of the box EXTREME EDUCATION

The Challenge Educating 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 Kids Playing/Fun not just for Kids It’s the doorway to learning It’s the doorway to learning Our mind is more alert and can learn faster and without barriers Our mind is more alert and can learn faster and without barriers Connects us to others provides a relaxed environment and works as team building Connects us to others provides a relaxed environment and works as team building Benefits of Playing and Fun at work Benefits 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 are doing." Dale Carnegie Fun Facts For Adults Do your Work or Play at the Job…?

TJC 2009 Time Line MDRO, CL and SSI TJC 2009 Time Line MDRO, CL and SSI April 1 st – Leadership Assigns Responsibility and oversight for compliance April 1 st – Leadership Assigns Responsibility and oversight for compliance July 1 st - Implementation Work plan in Place including resources needed July 1 st - Implementation Work plan in Place including resources needed October 1 st - Pilot testing in at least one clinical unit October 1 st - Pilot testing in at least one clinical unit January 1 st 2010 – Elements of performance fully implemented across the hospital January 1 st 2010 – Elements of performance fully implemented across the hospital

Initial Assessment NPSG #7 Assessment of processes in place meeting NPSG requirement : Assessment of processes in place meeting NPSG requirement :  Hand Hygiene Program and Audits in place ( less emphasis in 2010 ( observation)  Sentinel Event (deleted in 2010) Process in place  MDRO Flagging Process in place  Central line Protocol/ IHI Bundle Process in place  SCIP Protocol/Bundles Process in Place First Glance: We’re in GREAT SHAPE First Glance: We’re in GREAT SHAPE

On a Closer Look MDRO No Patient education implemented or documentation process No Patient education implemented or documentation process Measurement tool? Measurement tool? No formal education for staff No formal education for staff Measurement tool? Measurement tool? Isolation compliance hit and miss Isolation compliance hit and miss Measurement tool Measurement tool Venue for presenting quarterly MDRO surveillance Venue for presenting quarterly MDRO surveillance MDRO Flagging only on one system, not the system nurses use often MDRO Flagging only on one system, not the system nurses use often

Closer Look : Central Lines Prevention Element Only receiving 30 checklist/month from 150/month procedures Only receiving 30 checklist/month from 150/month procedures Central line carts on the floor/ checklist not used Central line carts on the floor/ checklist not used OR not using checklist OR not using checklist No patient education or documentation process No patient education or documentation process Protocol does not include scrub the hub Protocol does not include scrub the hub No formal education for staff No formal education for staff

The Closer Look Surgical Site Infection Prevention Education to patient includes what to expect in surgery /No education/documentation for patient on prevention measures for SSI prevention Education to patient includes what to expect in surgery /No education/documentation for patient on prevention measures for SSI prevention Measurement tool Measurement tool No formal education for staff except in OR No formal education for staff except in OR Measurement tool Measurement tool

The NPSG #7 Organizational Team Met BiWeekly April - July Met BiWeekly April - July Nursing Nursing Critical Care Critical Care OR OR Special Procedures Special Procedures Documentation Team Documentation Team Case Management Case Management Quality Improvement Quality Improvement All Responsible for taking 1 element of NPSG using The Cat in the Hat as a format Resulting in a Fun Rhyme for NPSG

BSA NPSG Comic Book

NPSG The Comic Book and Tools July 1 st – NPSG Comic Book Online for staff access July 1 st – NPSG Comic Book Online for staff access Dec 31 st – Deadline complete education and post test Dec 31 st – Deadline complete education and post test 2010 Jan 1 st – Compliance Audits 2010 Jan 1 st – Compliance Audits 2010 Jan 1 st NPSG 7 Monthly Education 2010 Jan 1 st NPSG 7 Monthly Education NPSG # 7 Education starts in New Nurse Orientation NPSG # 7 Education starts in New Nurse Orientation Unit Education and bookmarks Unit Education and bookmarks Sample of all NPSG Comic Book on Presentation Table

Staff Education Plan A : Housewide Education during Flu Vaccine Administration Plan A : Housewide Education during Flu Vaccine Administration Budget cuts and Flu Shortage Budget cuts and Flu Shortage Plan B: Monthly Snippet Education Plan B: Monthly Snippet Education MDRO, Cline, SSI MDRO, Cline, SSI IP develops and sends monthly IP develops and sends monthly One Page Information One Page Information Director/Educator responsible for staff education on unit Director/Educator responsible for staff education on unit Information kept on Education Board/30 days Information kept on Education Board/30 days #7 NPSG Notebook available on floor and online #7 NPSG Notebook available on floor and online Measurement for Staff Education Measurement for Staff Education – Net learning Post Test Bookmark, comic NPSG 7 to staff in staff meetings Bookmark, comic NPSG 7 to staff in staff meetings

Meet The Cat BSA Infection Preventionist

Infection Prevention NPSG #7

THING 1 Hand Hygiene NPSG 07.01

Hand Hygiene Components Housewide Goal 95% or > BSA Hand Hygiene Program BSA Hand Hygiene Program “ Gel to Excel ” “ Gel to Excel ” Program based upon CDC guidelines Program based upon CDC guidelines BSA Gold Standard: BSA Gold Standard: Hand Hygiene every time you enter pt room Hand Hygiene every time you enter pt room Patient Education Patient Education It’s Ok to Ask It’s Ok to Ask Hand Hygiene Audits monthly Hand Hygiene Audits monthly Each Clinical Dept Director responsible to submit a minimum of 10/month Each Clinical Dept Director responsible to submit a minimum of 10/month Outcome Audits provided monthly to each unit Outcome Audits provided monthly to each unit Nursing and Ancillary Directors Performance Evaluation depends upon their units HH rate Nursing and Ancillary Directors Performance Evaluation depends upon their units HH rate Secret Shoppers and Unit Observation Secret Shoppers and Unit Observation To keep the balance and to prevent Directors skewed perceptions To keep the balance and to prevent Directors skewed perceptions

Patient Education It’s Ok to Ask

Hand Hygiene Audit tool

Hand Hygiene Outcomes

Thing 3 Multiple Drug Resistant Organisms NPSG 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 Hromas Quality Specialist

MDRO Components Patient Education – online easy accessible Patient Education – online easy accessible MRSA C. Difficle VRE MRSA C. Difficle VRE Documentation in electronic record Documentation in electronic record Staff Education Staff Education Monthly MDRO Tips/ 2010 Monthly MDRO Tips/ 2010 Net learning 2011 Net learning 2011 Quarterly Risk Assessment of MDRO by unit Quarterly Risk Assessment of MDRO by unit Prevention Strategies Prevention Strategies Weekly Isolation Audits for each unit Weekly Isolation Audits for each unit MDRO Flagging – All systems MDRO Flagging – All systems

MDRO Education Patient Education Nurse Resources Easily Accessible English and Spanish

MDRO Patient Education

Staff Education (MDRO) Measurement Tool – Net Learning

Quarterly MDRO Risk Assessment by Unit

Weekly Audit Tool Measurement tool of Patient Education on Isolation

Directors Isolation Audit Outcomes Report

Flagging 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 4 Prevention of Central Line Infection NPSG

Components CL Policy with cleaning of HubCL Policy with cleaning of Hub Pt Ed/ DocumentationPt Ed/ Documentation Staff EducationStaff Education Central Line Insertion Cart with supplies Central Line Insertion Cart with supplies Central Line Checklist Central Line Checklist Central Line Bundle for Insertion Central Line Bundle for Insertion Hand Hygiene Hand Hygiene Maximal Barrier Precautions Upon Insertion Maximal Barrier Precautions Upon Insertion Chlorahexidine (CHG) Skin Antisepsis Chlorahexidine (CHG) Skin Antisepsis Optimal Catheter Site Selection, with avoidance of the Optimal Catheter Site Selection, with avoidance of the Femoral Vein for Central Venous Access in Adult Patients Femoral Vein for Central Venous Access in Adult Patients Daily Review of Line Necessity with Prompt Removal of unnecessary Lines Daily Review of Line Necessity with Prompt Removal of unnecessary Lines Risk Assessment and Outcome Risk Assessment and Outcome

Central Line Check List

Central Line Outcome Graph

Scrub the Hub Staff CL Education and Implemented in Protocol

Central Line Patient Education Documentation

Thing 5 Surgical Site Infection NPSG

Components SSI Policies for PreventionSSI Policies for Prevention Preprinted OrdersPreprinted Orders Patient EducationPatient Education Making Surgery Safer given Making Surgery Safer given in Pre Admit in Pre Admit Document on Patient Education on Universal Time out sheet Document on Patient Education on Universal Time out sheet Staff Education: Staff Education: OR competency on hire and annually OR competency on hire and annually Monthly SSI prevention Ed Monthly SSI prevention Ed Quarterly Risk Assessment on Targeted SSI Quarterly Risk Assessment on Targeted SSI

Pre Operative Antibiotic Order Set

Surgical Patient Education

Patient Education Documentation

SCIP Element # 9

Staff Education (SSI)

Surgical Site Infection Outcomes

DashBoard SSI Outcomes

NPSG SUMMARY NPSG SUMMARY So in summary you will find It will be best to keep in mind Number Seven is infection prevention You can do it without apprehension Remember these symbols they are quite easy Although the rhymes are somewhat cheesy These Four Things will prevent disaster Making Patient Safety at BSA the Master When Joint Commission comes through our door We will be prepared and receive a perfect score Charlotte Wheeler

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