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Infection Prevention – A Quality Assessment Performance Improvement (QAPI) Approach Phenelle Segal RN CIC President Infection Control Consulting Services www.iccs‐home.com 215‐692‐3485 info@iccs‐home.com
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Learning Objectives • Identify the CMS standards relating to ASC Infection Prevention and QAPI programs. • Recognize the relationships between
infection prevention activities and a QAPI program. • Describe the components of an infection prevention/QAPI program.
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Compliance – Federal Requirements
(ASCs) required to be in compliance with Federal requirements set forth in the Medicare Conditions for Coverage (CfC) in order to receive Medicare/Medicaid payment. 3
Compliance – Federal Requirements On November 18, 2008 the Centers for Medicare & Medicaid Services (CMS) adopted the Hospital Outpatient Prospective Payment System (OPPS) final rule: •
• • •
Revision to the ASC Conditions for Coverage (CfCs) took effect on May 18, 2009 at 42 CFR 416.2‐416.52. Included a large infection control component. CMS developed a surveyor worksheet in 2009 Revised version released June 2013.
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CMS Surveys
• Certification of ASC compliance accomplished through observations, interviews and document/record reviews. • The survey process focuses on delivery of patient care including: Organizational functions. Processes for the provision of care.
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CMS Surveys
The survey is the means used to assess compliance with Federal health, safety and quality standards that will assure that patients receive safe, quality care, and services.
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CMS Surveys
• ASCs who are accredited by any organization (AOs) may receive “deemed status”: The Joint Commission (TJC). Accreditation Association for Ambulatory Health Care (AAAHC). American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF). American Osteopathic Association (AOA).
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Conditions for Coverage (CfCs)
• § 416.43 ‐ Quality Assessment and Performance Improvement §416.43(a) Standard: Program Scope. §416.43(b) Standard: Program Data. §416.43(c) Standard: Program activities.
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Conditions for Coverage (CfCs)
• § 416.43 ‐ Quality Assessment and Performance Improvement §416.43(d) Standard: Performance Improvement Projects. §416.43(e) Standard: Governing Body responsibilities.
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Conditions for Coverage (CfCs)
• §416.51 – Infection Control §416.51(a) Standard: Sanitary Environment. §416.51(b) Standard: Infection Control Program.
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QAPI Program ‐ Requirements
• The ASC must develop, implement and maintain an ongoing, data‐driven quality assessment and performance improvement (QAPI) program. • Requires an ASC to take a proactive, comprehensive approach to improving the quality and safety of the surgical services it delivers.
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QAPI Program ‐ Requirements
The QAPI CfC presumes the following: • ASCs implement a systems approach to evaluating their processes. • Identify problems (potential or already occurred) that might result from the ASC’s practices. • Arrive at root causes of problems – resist superficially addressing one problem at a time.
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QAPI Program – “Must haves”
• Leadership • Governance 13
QAPI Program ‐ Elements
• • • • •
Program scope, design and development. Program implementation/activities. Program data use for monitoring/evaluation. In‐depth analysis and subsequent action plans. Feedback.
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QAPI Program ‐ Elements
Program Scope The program must include but not be limited to an ongoing program that demonstrates: • Measurable improvement in patient health outcomes. • Improves patient safety by using quality indicators or performance measures.
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QAPI Program ‐ Elements Program Activities The ASC must set priorities for its performance improvement activities that – • Focus on high risk, high volume, and problem‐prone areas. • Consider incidence, prevalence and severity of problems in those areas. • Affect health outcomes, patient safety and quality of care.
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Quality Indicators
There are a variety of types of indicators that are in use for measuring and improving quality of healthcare. Two indicators that link Infection Prevention with QAPI include: • Outcome indicators – data difficult to collect. • Process of care indicators – data more easily collected.
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Infection Prevention and QAPI
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Infection Prevention and QAPI • Maintain an infection control program that seeks to identify and minimize or prevent infections and communicable diseases. • Integration of IC plan into the (QAPI) program. • The infection control program be under the direction of a designated licensed healthcare professional with training in infection control.
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Infection Prevention and QAPI • Develop mechanisms to implement immediate corrective plans of action and prevention measures if the threat of spread of infection is identified in an ASC. • ASCs present unique challenges such as crowding in common areas and quick turnaround of OR suites and possible “short cuts” for reprocessing of instruments and other semi‐critical items/equipment.
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Infection Prevention and QAPI • Must include documentation that the ASC has considered, selected, and implemented nationally recognized infection control guidelines including: Centers for Disease Control and Prevention (CDC). The Association for Professionals in Infection Control and Epidemiology (APIC). The Society for Healthcare Epidemiology of America (SHEA). The Association of periOperative Registered Nurses (AORN).
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Infection Prevention and QAPI Leadership Governance Accountability Teamwork Committees – Infection Control (ICC) and QAPI • Goals and Objectives • Documentation • Performance Measures
• • • • •
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Infection Prevention and QAPI Quality Indicators Healthcare Outcomes Healthcare Processes Risk Assessment – high risk, high volume, problem‐prone • Surveillance and data collection • Data analysis • Competencies • • • •
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Infection Prevention and QAPI • • • • • • • •
Root Cause Analysis Meaningful feedback Education Level of training Environmental Services OSHA compliance Reporting –internal and external Action Plans 24
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Infection Prevention Quality Reporting Program Measures • Centers for Medicare and Medicaid (CMS) quality reporting program finalized in calendar year (CY) 2012. • 4 outcome measures and 1 process measure adopted for CY 2014 payment determination. • CY 2014 payment determination process measure related to infection control: Prophylactic antibiotic timing – aligned with current surgical infection prevention guidelines
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Infection Prevention Quality Reporting Program Measures 2 infection control related measures failed adoption due to inappropriateness for ASCs Selection of prophylactic antibiotic: National Quality Forum (NQF) adopted this measure for hospitals inpatient and outpatient quality reporting programs Negative public comments and a general consensus created the decision by CMS to forego adoption 26
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Infection Prevention Quality Reporting Program Measures Public reporting of Healthcare Associated Infections (HAIs): Surgical Site Infection (SSI) rate measure reporting to Centers for Disease Control (CDC). National Quality Forum (NQF) adopted this measure for inpatient quality reporting programs. This measure will be reconsidered in the future. Some states have adopted public reporting requirements for ASCs independent of CMS.
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Infection Prevention Quality Reporting Program Measures CY 2014 payment determination process measure related to infection control: ASC‐5: Prophylactic antibiotic timing CY 2016 payment determination process measure related to infection control: ASC‐8: Influenza vaccination coverage among healthcare personnel (HCP): 28
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QAPI Program ‐ Assessment
Structured project planning method used to evaluate the following: • Strengths • Weaknesses • Opportunities • Threats
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Reprocessing of Endoscopes The Duodenoscope Dilemma
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Phenelle Segal RN CIC President Infection Control Consulting Services www.iccs‐home.com 215‐692‐3485 info@iccs‐home.com
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References CMS State Operations Manual Appendix L – Guidance for Surveyors – Ambulatory Surgical Centers: (Rev.99, 01‐31‐14): http://www.cms.gov/Regulations‐and‐ Guidance/Guidance/Manuals/downloads/som107ap_l_ambulatory.p df ASC Infection Control Surveyor Worksheet: http://www.cms.gov/Regulations‐and‐ Guidance/Guidance/Manuals/downloads/som107_exhibit_351.pdf
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