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The Joint Commission NPSG

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 48 Critical care beds 20 Bed Level 1 NICU unit 15,000 surgical procedures/year

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The Joint Commission NPSG

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

  2. Baptist St. Anthony’s Health SystemAmarillo Texas

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

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

  5. The ChallengeEducating 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”

  6. Fun Facts For Adults Do your Work or Play at the Job…? • Playing/Fun not just for Kids • It’s the doorway to learning • 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 • Benefits of Playing and Fun at work • keeps you functional when under stress • refreshes your mind and body • encourages teamwork • helps you see problems in new ways • triggers creativity and innovation • increases energy and prevents burnout "People rarely succeed unless they have fun in what they are doing." Dale Carnegie http://www.helpguide.org/life/creative_play_fun_games.htm

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

  8. Initial Assessment NPSG #7 • 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

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

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

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

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

  13. BSA NPSG Comic Book

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

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

  16. Meet The Cat BSA Infection Preventionist

  17. Infection PreventionNPSG #7

  18. THING 1 Hand Hygiene NPSG 07.01

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

  20. Patient EducationIt’s Ok to Ask

  21. Hand Hygiene Audit tool

  22. Hand Hygiene Outcomes

  23. Thing 3 Multiple Drug Resistant Organisms NPSG 07.03.01 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

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

  25. MDRO EducationPatient Education • Nurse Resources • Easily Accessible • English and Spanish

  26. MDRO Patient Education

  27. Staff Education (MDRO)Measurement Tool – Net Learning

  28. Quarterly MDRO Risk Assessment by Unit

  29. Weekly Audit Tool Measurement tool of Patient Education on Isolation

  30. DirectorsIsolation Audit Outcomes Report

  31. 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.

  32. Thing 4 Prevention of Central Line Infection NPSG 07.04.01

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

  34. Central Line Check List

  35. Central LineOutcome Graph

  36. Scrub the Hub Staff CL Education and Implemented in Protocol

  37. Central LinePatient Education Documentation

  38. Thing 5 Surgical Site InfectionNPSG 07.04.01

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

  40. Pre OperativeAntibiotic Order Set

  41. Surgical Patient Education

  42. Patient EducationDocumentation

  43. SCIP Element # 9

  44. Staff Education (SSI)

  45. Surgical Site InfectionOutcomes

  46. DashBoard SSI Outcomes

  47. 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 1. 3. 4. 5. NPSG SUMMARY

  48. Questions

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