Phenelle infection prevention and control presentation 2015

3/27/2015

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.

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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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