Stony Brook Medicine Response to Quality Assurance and Performance Improvement Overview
“The Stony Brook Way is My Way”
Stony Brook Medicine: Response to Quality Assurance and
Performance Improvement
What We Need to Know
New York State Department of Health
Center for Medicaid Medicare Services
[CMS]
All Cause Corrective Action
Stony Brook Medicine
Developed 6/10/2015
Reviewed 6/19/2015 cm
DOH/CMS Areas of Deficiency:
1.
Allegations of Sexual, Physical, or Psychological
Abuse
2.
Infection Control Practices
3.
Intravenous Therapy and Blood Product
Administration
4.
HIPAA, as it relates to PHI Disclosure
5.
Code Cart Standardization
“The Stony Brook Way is My Way”
1.
Didactic education
2.
Skills based training and Simulation
3.
Attestation- confirmed completion
4.
Validation- check performance
5.
Outcomes- compliance
IMPLEMENTATION /COMMUNICATION
STRATEGY
“The Stony Brook Way is My Way”
•
D
O
H
f
o
r
C
M
S
A
l
l
e
g
a
t
i
o
n
s
u
r
v
e
y
4
/
2
8
/
1
5
–
5
/
4
/
1
5
•
Finding related to process for investigation of patient complaints of
Abuse & Neglect by a Staff member
•
Actions:
New Policy
RI0057:
Patient Allegations of Abuse/Neglect by a Staff
Member
implemented prior to DOH exit
Education to front line, managers, supervisors, directors & medical
staff via PPs, LMS, and continuing through annual re-certifications
and new employee orientation
Abuse Complaint checklist to document actions
Policy: RI:0057
https://policymanager.uhmc.sunysb.edu/dotNet/documents/?docid=6063
&mode=view
C
M
S
A
L
L
E
G
A
T
I
O
N
S
U
R
V
E
Y
“The Stony Brook Way is My Way”
•
CMS document received evening of 6/3/2015 (
on day 3 of TJC Survey
)
•
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6
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•
Requires 100% monitoring of responses to Abuse & Neglect complaints (13
to date since DOH visit)
•
Requires feedback to Departments on Abuse & Neglect complaints
•
Requires tracking & trending by department and individual
C
M
S
R
E
P
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T
5
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3
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“The Stony Brook Way is My Way”
“The Stony Brook Way is My Way”
Administrative Policy on Isolation Precautions IC 0006
As soon as patients are identified as needing isolation:
•
Yellow card / chart, dedicated stethoscope / thermometer
•
All rooms must have a Personal Protection Equipment [PPE] cabinet
in or in close proximity to the entryway
•
Cabinets must be stocked with gowns, gloves, surgical masks,
goggles and / or face shields
•
All HCWs are responsible for following the isolation precautions
delineated in the Hospital Policy and reminding other HCWs to do the
same
•
Families must be educated re: Hand hygiene practices and Patient’s
isolation
HEALTHCARE EPIDEMIOLOGY DEPARTMENT
“The Stony Brook Way is My Way”
All patients, regardless of status:
•
inpatient
•
outpatient
•
observation
Must be placed on the
correct isolation precautions
based
upon the patient’s:
•
personal history
•
clinical presentation
•
isolation code on Banner Bar
HEALTHCARE EPIDEMIOLOGY DEPARTMENT
“The Stony Brook Way is My Way”
Administrative Policy on Hand Hygiene IC 0003
Hand Hygiene is performed:
•
U
pon entering & exiting patient rooms
•
Before and after any contact with patient / environment, regardless
of +/- isolation status
•
In between dirty and clean procedures
•
Between separate portions of the physical exam re: clean vs dirty
•
OK to foam
when entering
a
C diff
room, but must wash hands
with
SOAP / WATER
upon exiting
Families must be educated on hand hygiene practices
DEP
HEALTHCARE EPIDEMIOLOGY DEPARTMENT
ORMATICS
“The Stony Brook Way is My Way”
Administrative Policy on Infection Control in patient transporting IC 0007
Patients on isolation must be transported using practices that minimize
cross contamination
If patient is on isolation, the transporter must:
•
Perform hand hygiene, don correct PPE identified on the isolation yellow card before
entering room
•
Bring clean transfer equipment into the room, transfer patient to stretcher or wheelchair
as indicated
•
Cover patient with clean sheet
•
Remove isolation garb before exiting room, perform hand hygiene
•
When transferring patient on occupied bed, wipe the side rails and all accompanying
equipment with antimicrobial (purple) wipes, allowing for 2 minute dwell time prior to
exiting the room
HEALTHCARE EPIDEMIOLOGY DEPARTMENT
“The Stony Brook Way is My Way”
Administrative Policy on Infection Control in Patient Transporting IC 0007
•
Patients on droplet and airborne precautions must
themselves wear a well fitted surgical mask during
transport prior to leaving the room to contain their
secretions, thus preventing dissemination
•
All other patients do not require a mask as the
mode/mechanism of transmission is not via droplet
secretion
“The Stony Brook Way is My Way”
H
e
a
l
t
h
C
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e
P
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)
:
•
From patient to patient
•
From room to room
•
When used on a patient with an infection, discard after use
Use single-dose containers whenever possible
When single-dose dispensers are not available:
•
Maintain aseptic technique
•
Perform hand hygiene
•
Prevent tip of dispenser from touching the patient
•
Wipe down container with antimicrobial (purple) wipes in between
every patient encounter and prior to returning it to the case.
HEALTHCARE EPIDEMIOLOGY DEPARTMENT
SBU Hospital Infection Control Policies
•
Hand Hygiene IC 0003
•
Multidrug Resistant Organisms (M-RO) IC 0010
•
Patient Care Equipment Cleaning IC 0013
•
Infection Control In Patient Transporting IC 0007
•
Isolation Precautions IC 0006
•
Prevention and Control of
Clostridium defficile
IC 0022
•
Prevention and Transmission of
M. Tuberculosis
infection IC
0011
•
MM0012 Multiple Dose Vials, Multiple Use Containers
•
IC0012 Standard Precautions
Infection Control is in Your Hands
All consultants [MDs, NPs, PAs, etc] will
notify primary nurse of their arrival prior to
entering patient room in ED and on the Units:
“I’m here to see patient ____. Is there
anything I should know?”
“The Stony Brook Way is My Way”
Audit and analysis of all IV and Blood
Administration Policies
Development of educational materials
aligned with best practices and SBUH
policies
•
Development of Skills Training stations
•
Development of Simulation scenarios
•
Training of Auditors
•
Systematic ongoing monitoring
IV THERAPY AND BLOOD ADMINISTRATION
“The Stony Brook Way is My Way”
Removed complete patient name from
slave monitors
•
Rolling computer carts: instructing and
auditing for open EMRs with PHI on the
screen
•
Education on the proper communication of
PHI, with instruction for sensitivity to the
environment and other people: only
permitted use
of incidental disclosure
HIPAA COMPLIANCE: PROTECTED
HEALTHCARE INFORMATION
“The Stony Brook Way is My Way”
All Pediatric and Adult Code Carts now
include the appropriate Zoll Pads
Pediatric Code Cart now contains two sets
of Zoll Pads: Children less than 8 years of
age and over 8 years of age
All Code Carts now have consistent Code
Cart checklists
CODE CART STANDARDIZATION
“The Stony Brook Way is My Way”
Accountability
•
Attestation of all staff by 6/15/2015
•
Validation of training and education 6/15-6/20/2015
•
Remediation directives-as it occurs
•
Behavior-Based Expectations- continuous
•
Ongoing monitoring of outcomes
•
Patient Safety Rounding will include CMS
Hospital Infection Control
Worksheet
with relevant scoring
.
ALL CAUSE CORRECTIVE ACTIONS
“The Stony Brook Way is My Way”
Stony Brook Medicine developed corrective actions in response to deficiencies identified by the DOH/CMS related to patient care and compliance. Implementation strategies include education, training, and validation processes. The healthcare facility's approach emphasizes a culture of accountability and continuous improvement.
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Presentation Transcript
Stony Brook Medicine: Response to Quality Assurance and Performance Improvement What We Need to Know New York State Department of Health Center for Medicaid Medicare Services [CMS] All Cause Corrective Action Stony Brook Medicine Developed 6/10/2015 Reviewed 6/19/2015 cm The Stony Brook Way is My Way
DOH/CMS Areas of Deficiency: 1. Allegations of Sexual, Physical, or Psychological Abuse 2. Infection Control Practices 3. Intravenous Therapy and Blood Product Administration 4. HIPAA, as it relates to PHI Disclosure 5. Code Cart Standardization The Stony Brook Way is My Way
IMPLEMENTATION /COMMUNICATION STRATEGY 1. Didactic education 2. Skills based training and Simulation 3. Attestation- confirmed completion 4. Validation- check performance 5. Outcomes- compliance The Stony Brook Way is My Way
CMS ALLEGATION SURVEY DOH for CMS Allegation survey 4/28/15 5/4/15 Finding related to process for investigation of patient complaints of Abuse & Neglect by a Staff member Actions: New Policy RI0057: Patient Allegations of Abuse/Neglect by a Staff Member implemented prior to DOH exit Education to front line, managers, supervisors, directors & medical staff via PPs, LMS, and continuing through annual re-certifications and new employee orientation Abuse Complaint checklist to document actions Policy: RI:0057 https://policymanager.uhmc.sunysb.edu/dotNet/documents/?docid=6063 &mode=view The Stony Brook Way is My Way
CMS REPORT 5/13/2015 CMS document received evening of 6/3/2015 (on day 3 of TJC Survey) Follow up actions and clarification statements to be submitted by 6/15/2015 Requires 100% education : Medical Staff must complete to 100% by 6/15/2015 Requires 100% monitoring of responses to Abuse & Neglect complaints (13 to date since DOH visit) Requires feedback to Departments on Abuse & Neglect complaints Requires tracking & trending by department and individual The Stony Brook Way is My Way
HEALTHCARE EPIDEMIOLOGY DEPARTMENT Administrative Policy on Isolation Precautions IC 0006 As soon as patients are identified as needing isolation: Yellow card / chart, dedicated stethoscope / thermometer All rooms must have a Personal Protection Equipment [PPE] cabinet in or in close proximity to the entryway Cabinets must be stocked with gowns, gloves, surgical masks, goggles and / or face shields All HCWs are responsible for following the isolation precautions delineated in the Hospital Policy and reminding other HCWs to do the same Families must be educated re: Hand hygiene practices and Patient s isolation The Stony Brook Way is My Way
HEALTHCARE EPIDEMIOLOGY DEPARTMENT All patients, regardless of status: inpatient outpatient observation Must be placed on the correct isolation precautions based upon the patient s: personal history clinical presentation isolation code on Banner Bar The Stony Brook Way is My Way
DEPHEALTHCARE EPIDEMIOLOGY DEPARTMENT ORMATICS Administrative Policy on Hand Hygiene IC 0003 Hand Hygiene is performed: Upon entering & exiting patient rooms Before and after any contact with patient / environment, regardless of +/- isolation status In between dirty and clean procedures Between separate portions of the physical exam re: clean vs dirty OK to foam when entering a C diff room, but must wash hands with SOAP / WATER upon exiting Families must be educated on hand hygiene practices The Stony Brook Way is My Way
HEALTHCARE EPIDEMIOLOGY DEPARTMENT Administrative Policy on Infection Control in patient transporting IC 0007 Patients on isolation must be transported using practices that minimize cross contamination If patient is on isolation, the transporter must: Perform hand hygiene, don correct PPE identified on the isolation yellow card before entering room Bring clean transfer equipment into the room, transfer patient to stretcher or wheelchair as indicated Cover patient with clean sheet Remove isolation garb before exiting room, perform hand hygiene When transferring patient on occupied bed, wipe the side rails and all accompanying equipment with antimicrobial (purple) wipes, allowing for 2 minute dwell time prior to exiting the room The Stony Brook Way is My Way
Administrative Policy on Infection Control in Patient Transporting IC 0007 Patients on droplet and airborne precautions must themselves wear a well fitted surgical mask during transport prior to leaving the room to contain their secretions, thus preventing dissemination All other patients do not require a mask as the mode/mechanism of transmission is not via droplet secretion The Stony Brook Way is My Way
HEALTHCARE EPIDEMIOLOGY DEPARTMENT Health Care Providers are NOTto carry multi-dose vials in pockets or case (pharmacy policy modified): From patient to patient From room to room When used on a patient with an infection, discard after use Use single-dose containers whenever possible When single-dose dispensers are not available: Maintain aseptic technique Perform hand hygiene Prevent tip of dispenser from touching the patient Wipe down container with antimicrobial (purple) wipes in between every patient encounter and prior to returning it to the case. The Stony Brook Way is My Way
SBU Hospital Infection Control Policies Hand Hygiene IC 0003 Multidrug Resistant Organisms (M-RO) IC 0010 Patient Care Equipment Cleaning IC 0013 Infection Control In Patient Transporting IC 0007 Isolation Precautions IC 0006 Prevention and Control of Clostridium defficile IC 0022 Prevention and Transmission of M. Tuberculosis infection IC 0011 MM0012 Multiple Dose Vials, Multiple Use Containers IC0012 Standard Precautions Infection Control is in Your Hands
All consultants [MDs, NPs, PAs, etc] will notify primary nurse of their arrival prior to entering patient room in ED and on the Units: I m here to see patient ____. Is there anything I should know? The Stony Brook Way is My Way
IV THERAPY AND BLOOD ADMINISTRATION Audit and analysis of all IV and Blood Administration Policies Development of educational materials aligned with best practices and SBUH policies Development of Skills Training stations Development of Simulation scenarios Training of Auditors Systematic ongoing monitoring The Stony Brook Way is My Way
HIPAA COMPLIANCE: PROTECTED HEALTHCARE INFORMATION Removed complete patient name from slave monitors Rolling computer carts: instructing and auditing for open EMRs with PHI on the screen Education on the proper communication of PHI, with instruction for sensitivity to the environment and other people: only permitted use of incidental disclosure The Stony Brook Way is My Way
CODE CART STANDARDIZATION All Pediatric and Adult Code Carts now include the appropriate Zoll Pads Pediatric Code Cart now contains two sets of Zoll Pads: Children less than 8 years of age and over 8 years of age All Code Carts now have consistent Code Cart checklists The Stony Brook Way is My Way
ALL CAUSE CORRECTIVE ACTIONS Accountability Attestation of all staff by 6/15/2015 Validation of training and education 6/15-6/20/2015 Remediation directives-as it occurs Behavior-Based Expectations- continuous Ongoing monitoring of outcomes Patient Safety Rounding will include CMS Hospital Infection Control Worksheet with relevant scoring. The Stony Brook Way is My Way
