Helen Bucknell FAAQHC CICP Cert IV TAE RN BN Quality and Infection - - PowerPoint PPT Presentation

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Helen Bucknell FAAQHC CICP Cert IV TAE RN BN Quality and Infection - - PowerPoint PPT Presentation

Jan 08, 2023 193 likes •446 views

Helen Bucknell FAAQHC CICP Cert IV TAE RN BN Quality and Infection Control Consultant Session Outline Draft Revised Standard 3 criteria (not yet endorsed) Main changes or focus areas Content of draft action items Links to other

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Helen Bucknell

FAAQHC CICP Cert IV TAE RN BN Quality and Infection Control Consultant

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Draft Revised Standard 3 criteria

(not yet endorsed)

  • Main changes or focus areas
  • Content of draft action items
  • Links to other draft standards
  • Summary

Session Outline

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ADVERSE OUTCOMES RELATED TO Healthcare Acquired Infections

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Current version NS 3 has 41 action items Draft revision has 16 action items

BUT (some have many subsets)

The new version remains:

  • Broad, Multidisciplinary
  • Multifactorial
  • Will require data analysis, monitoring, reporting

structures

  • Must show evidence of continuous improvement for

patient and staff safety

NSQHSS 3 snapshot

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1. Governance and systems for infection prevention, control and surveillance 2. Infection prevention and control strategies 3. Managing patients with infections or colonisations 4. Antimicrobial stewardship 5. Cleaning, disinfection and sterilization 6. Communicating with patients and carers 6 overarching criteria 1. Clinical governance & quality improvement to prevent and control HAI, and support antimicrobial stewardship 2. Infection prevention and control systems 3. Reprocessing of reusable medical devices 4. Antimicrobial stewardship 4 overarching criteria

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MAIN CHANGES

  • Increased focus on risk management
  • AMS (now includes the requirement to meet the

Clinical Care Standard)

  • Reprocessing of Reusable Medical Devices – now

stand alone criteria.

  • Language and definitions changed slightly to

make meanings clearer.

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Intent of standard 3 (version 1 NSQHSS):

Prevent patients from acquiring preventable HAI and effectively manage infections when they occur by using evidence-based strategies.

Intent of draft standard 3 (version 2 NSQHSS):

Reduce the risk of patients acquiring preventable HAI, effectively manage infections if they occur, and limit the development of antimicrobial resistance through prudent use of antimicrobials as part of antimicrobial stewardship.

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NSQHSS 1 Clinical Governance

NSQHSS 3 Infection Prevention & Control Other Responsibilities : Quality, Clinical, Maintenance etc Service Delivery: Nursing and other Staff, Clinicians, Maintenance, Environmental Services, Medication, Catering etc

OPERATIONAL STAFF & PATIENT SAFETY

Patient Outcomes & engagement

FEEDBACK

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Version 2 (draft) 3.1 Integrating clinical governance

Workforce uses safety and quality systems from the clinical governance of the organisation for:

Policies and procedures, managing risk, training and antimicrobial stewardship (AMS).

Link to V1 (3.1.1, 3.1.2, 3.3.1, 3.5.2, 3.7.1, 3.9.1, 3.15.2, 3.18.1)

3.2 Applying quality improvement systems

Organisation applies the quality improvement system in the Clinical Governance Standard when:

Monitoring systems for preventing and controlling HAI. Implementing strategies to improve outcomes of IC systems. Reporting and taking action on outcomes of HAI.

Link to V1 (3.1.2,3.1.3, 3.1.4, 3.3.2, 3.4.1, 3.4.2, 3.4.3.3.10.3.3.112, 3.11.3.3.11.4, 3.11.5, 3.14.3)

Clinical Governance & Quality Improvement

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Version 2 (draft)

3.3 Partnering With Consumers

Linking with Standard 2 to:

  • Actively involve consumers in their care
  • Meet patient information needs
  • Share decision making

Link to V1 (3.19.1, 3.19.2)

3.4 Surveillance

Surveillance strategies that include:

  • Data collection
  • Monitoring and use of surveillance data to reduce risks
  • Reporting data to the workforce, governing body and

consumers

Link to V1 (3.2.1, 3,2,2)

Clinical Governance & Quality Improvement

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Version 2 (draft) 3.5 Standard and transmission based precautions consistent with state and national guidelines / IC requirements 3.6 Assess risks and use transmission based precautions (7 criteria) 3.7 Communicating infectious status when transferring care

Link to V1 (3.7.1, 3.11.1, 3.12.1, 3.13.1, 3.13.2) Infection Prevention & control Systems

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Version 2 3.8 Hand Hygiene

Program consistent with national and jurisdictional requirements. Address non compliance.

Link to V1 (3.5.1, 3.5.3)

3.9 Aseptic Technique

Identifying where AT applies, staff training, addressing gaps in competency. Monitoring compliance.

Link to V1 (3.10.1, 3.10.2)

Infection Prevention & control Systems

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Version 2 (draft)

3.10 Invasive Medical Devices

Use and management of invasive devices in accordance with national IC guidelines.

Link to V1 (3.8.1)

Infection Prevention & control Systems

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Version 2 (draft) 3.11 Maintaining clean and hygienic environment:

  • Responding to risks, training staff

3.12 Processes to evaluate and respond to infection risks for:

  • New and existing equipment, devices and

products

  • Maintaining, and upgrading buildings,

equipment, furnishings and fittings

  • Handling, transporting and storing linen

Link to V1 (3.15.1, 3.15.3 and NEW COMPONENTS 3.12 )

Infection Prevention & control Systems

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Version 2 (draft) 3.13 Risk based immunisation program that is:

  • Consistent with national guidelines and

jurisdictional requirements

  • Addresses specific risks to the workforce and

patients

Link to V1 (3.6.1)

Infection Prevention & control Systems

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Version 2 (draft) 3.14 Processes for Reusable equipment, instruments and devices consistent with

relevant national and international standards and manufacturer's guidelines – 5 year implementation plan. Traceability process to identify:

  • Patient
  • Procedure
  • Reusable equipment, instruments and devices

Link to V1 (3.16.1, 3.17.1)

Reprocessing of reusable medical devices

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3.15 Antimicrobial Stewardship program; includes:

  • Policy
  • Promotion of therapeutic guidelines
  • Approved formulary
  • Inclusion of Clinical Care standard for AMS

3.16 The program will:

  • Review prescribing and use
  • Use surveillance data to support prescribing
  • Report outcomes to clinicians and governing

committee; implement improvements

Link to V 1 (3.14.1, 3.14.2, 3.14.3, 3.14.4)

Antimicrobial stewardship

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Antimicrobial Stewardship Clinical Care Standard 3.15 d

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STANDARD 3 PREVENTING AND CONTROLLING HAI Governance Policies Tools Audits Training Quality Improvement STANDARD 1

CLINICAL GOVERNANCE FOR HEALTH SERVICE ORGANISATIONS

STANDARD 2

PARTNERING WITH CONSUMERS

STANDARD 8

ACUTE DETERIORATION

STANDARD 7

BLOOD MANAGEMENT

STANDARD 4

MEDICATION SAFETY

STANDARD 6

COMMUNICATING FOR SAFETY

STANDARD 5

COMPREHENSIVE CARE

REVISED DRAFT STANDARD 3 AND LINKS WITH OTHER STANDARDS

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Summary

  • New draft standard 3 - will remain broad, multi-

disciplinary and require significant evidence

  • Defined and documented Clinical Governance

framework

  • Continue progression of 5 year AS/NZS 4187: 2014

plan

  • Although there are 16 overarching action items

there are 36 actions in total counting subsets!

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  • Exploring Context for effective clinical governance in

infection control (2016) Halton Kate, Hall Lisa, Gardner Ann Macbeth Deborough, Mitchell Brett AJIC (Dec 2 2016)

  • Australian Commission on Safety and Quality in Health

Care (2016) National safety and Quality Health Service Standards Version 2. Sydney, Australia: Australian Commission on Safety and Quality in Health Care

  • National Health and Medical Research Council (2010)

Australian guidelines for the prevention and control of infection in healthcare. Canberra, Australia: Commonwealth of Australia

References

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  • Review policies and procedures - facility specific
  • Monitor Compliance & HAI Surveillance data
  • Environmental surveillance and compliance
  • Review of IC incidents and complaints
  • Reporting and risk identification (review of IC risks on risk register)
  • Endorsement of audit tools and surveys ,
  • Training Needs Analysis and monitoring training compliance
  • Monitoring compliance rates with HCW immunisation programs
  • Quality activities / Continuous Improvement to reduce HAI
  • Managing

up and reporting accurately

  • n

achievements and shortfalls/risks in the program

  • Reports on other items e.g antimicrobial stewardship, reprocessing

RMDs, clinical product review Attachment 1 IC Governance

Standing agenda Items (the Minimum)