National Safety and Quality Health Service Standards

Standard 3 – Preventing and Controlling HAIs

August 25, 2014

Sue GreigSenior Project Officer, ACSQHC

Standard 7Blood and Blood

Products

Standard 10Preventing Falls and

Harm from Falls

The NSQHS Standards

Standard 1Governance for Safety and

Quality in Health Service Organisations

Standard 2Partnering withConsumers

Standard 4Medication Safety

Standard 3Healthcare AssociatedInfections

Standard 8Preventing and

Managing Pressure Injuries

Standard 9Recognising and

Responding to ClinicalDeterioration in Acute

Health Care

Standard 5Patient Identificationand ProcedureMatching

Standard 6ClinicalHandover

National Safety and Quality Standards

• Approved by health ministers September 2011

• Address areas where:• Large numbers of patients effected• Known gap between current situation

and best practice outcomes• Evidence based, achievable

improvement strategies exist

Key points

1. Standards are about safe patient care

2. Safety and quality is an organisational responsibility

3. Communicate and plan together

4. Gap analysis and risk assessment

5. Prioritising – decision grid

A patient’s perspective of health care …

I have a right to safe and high quality care.

This means:- To be free of being infected by my hospital or health

worker- To be given the right medications at the right time- To be assessed for the risk of VTE- To have the correct procedure, operation, test, x-ray- To be rescued if my condition unexpectedly

deteriorates

The quality and safety problem

• The gap between the delivery of recommended care and the care that is actually provided can be as high as 50%.

Why ? • Is it …

• Ignorance

• Lack of training• The lack of applied ‘common sense’• Mobility of HCWs• Inconsistent curriculums and assessment of competence• Inconsistent practices and resources• Lack of access to evidence based information• Care is too complex• Patients are too complex• We are too busy • Not enough staff• Clinicians don’t care

Is it all just too hard????

Standard 3 – Preventing and Controlling Healthcare Associated Infections

•Applied in conjunction with

• Standard 1, ‘Governance for Safety and Quality in Health Service Organisations’

• Standard 2, ‘Partnering with Consumers’• Standard 4, ‘Medication Safety’• Standard 6, ‘Clinical Handover’

Why have a Standard about preventing infection?

• preventable

• common

• increase morbidity, mortality, pain & suffering

• cost to patients, hospital staff, health system

• no single solution

• range of strategies

Criteria for Standard 3

• Governance and systems for IPC and surveillance• Strategies for IPC• Managing patients with infections or colonisation• AMS• Cleaning, disinfection or sterilisation• Communicating with patients and carers

Benefits of Standard 3

• Reduce risk of patient harm and death• Clarifies roles, responsibilities and

accountabilities • Improves information • Antimicrobial stewardship • Improves organisational governance • Tracking of invasive, reusable devices• Increases focus on specific evidence based

strategies

Priorities for Standard 3

• Effective governance • Identifying what is working well• Knowing your risks and/or gaps• Having systems to gather, review and report

evidence• Having a plan to address risks and respond • Aim for the best (either 0 or 100%)• Ability to demonstrate progress/improvement• Engage with others in the organisation

What is different?

• Responsibility of governance and management systems

• Making a difference to patient safety• Managing risk• Evidence of process, systems and outcomes• Recognition of the consumer as a partner

Top tips for responding to Standard 3

• Assess the current situation• Risk assessment • Current governance arrangements• Current policies, processes and resources• Data currently collected • Any audit results • Current resistance patterns, infections

• Raise awareness• Share results, ask for interested people to be

involved

How have organisations performed so far?

• 737 organisations assessed against Std 3 - organisational wide (275), mid-cycle (445) and interim assessments (17)

• 1352 public, private and day procedure services eligible to be assessed in Australia

• In 2013, of the 1352 eligible services >50% have been surveyed and have met Standard 3 requirements

How have organisations performed so far?

In 2013:•55% were private organisations•45% were public organisations•60% of public organisations met all core actions at initial assessment•55% of private organisations met all core actions at initial assessment•90% of organisational wide surveys had core and developmental actions to be addressed within 120days•32% of organisational wide surveys had core only actions to be addressed within 120days

Where to from here

• Review of the current Standards by 2017• Ongoing accreditation of health service

organisations• Review of the accrediting agencies accreditation

scheme• Improve on inter-ratter reliability• Further review of the data received on the first 12

months• Ongoing support for organisations and agencies

with development of resources to assist with responding to the Standards

Criteria for Standard 3

• Governance and systems for IPC and surveillance• Strategies for IPC• Managing patients with infections or colonisation• AMS• Cleaning, disinfection or sterilisation• Communicating with patients and carers

Cleaning, disinfection and sterilisation

Links between Standard 1 and Standard 3 as well as within Standard 3 with criteria – Governance and Cleaning, Disinfection and Sterilisation

•3.15 – Environmental cleaning•3.16 – Reprocessing reusable medical equipment, instruments and devices•3.17 – Identification of patients on whom reusable medical devices have been used (traceability)•3.18 – Competency based training for those who are involved in decontamination of reusable medical devices

How times have changed….

• 1941 – “Husbands are like Kleenex – soft, strong and dependable” Ball of Fire

• 1985 – “Husbands are like Kleenex – soft, strong and disposable” Clue

• Sterilising services are an area that has experienced change in the last 30 years both with technology and scope of services.

“I am a pushover for Streptococcus”Sugarpuss O’Shea (Barbara Stanwick), Ball of Fire, 1941

3.16.1 - Reprocessing reusable medical equipment, instruments and devices in accord with relevant national or international standards and manufacturer instructions.

Why?• Minimise risks of infection to patients and the workforce

How?• Governance - 3.1.1 organisational risk assessment and policy,

procedures and/or protocols

3.16.1 When looking at risk consider:

• What reprocessing the organisation needs to consider based on services provided

• Are there policies, procedures and protocols to cover the scope of services provided

• How will the organisation achieve this – equipment and consumables

• Outsourcing to external providers• Single use items• Purchase of sterile stock• Providing reprocessing services to other

organisations/individuals

What other evidence supports 3.16.1

• Product selection • Equipment and environmental maintenance that

includes schedules, fault and variance reporting• Quality control systems that include document control,

audit and compliance reports• Incident reports• Education or training for the introduction of new products

and equipment

“Tag ‘em and bag ‘em” Platoon 1986

3.17.1 - Identification of patients on whom reusable medical devices have been used (traceability)

Why?•Minimise risk to patients of contracting infection from reusable medical devices

How?•Look at what current systems are and can they be improved?

“Dobby didn’t mean to kill – Only maim and seriously injure” Harry Potter and the Deathly Hallows, 2011 – Dobby the house elf

What are the risks relating to traceability?

•Can the organisation identify reusable medical devices?

•Can the organisation identify on which patient these items were used?

•Can the organisation do this retrospectively?

“ Practice makes perfect” Clue 1985

3.18.1 - Competency based training for those who are involved in decontamination of reusable medical devices.

Why?•Appropriate and correct decontamination is critical to reprocessing of reusable medical devices to reduce risk of infection

How?•Provision of appropriate training to those who undertake decontamination and assessing competence of the relevant workforce.

“What we’ve got here is a failure to communicate” Cool Hand Luke, 1967– Paul Newman

What are some of the risks to consider:

•Look at where decontamination occurs and who undertakes the task?•Have they been trained?•How and by what method?•Is the training current and in line with best practice?•Is the training consistent?•Do they have the resources to safely undertake decontamination?•Is competency assessed and if so – by whom/how?

“The subconscious does not make mistakes” Ball of Fire, 1941- Gary Cooper, Barbara Stanwick

The key points for an organization to consider for cleaning, disinfection and sterilization of reusable medical devices are:•Risk assess the scope of services in the organisation•Engage with governance to respond to identified risks•Have policies, procedures and protocols to cover the scope of services•Have a system to identify patients on whom reusable medical devices have been used (traceability)•Identify and then provide or access competency based training for those who are involved in decontamination of reusable medical devices.

Last ‘classic’ quote……

Let whoever is in charge keep this simple question in her head – not how can I always do this thing right myself, but

how can I provide for this right thing to be always done?

Florence Nightingale

For further assistance…….

Advice Centre 1800 304 056accreditation@safetyandquality.gov.au

Service will consist of: •Dedicated telephone line operated during business hours•Dedicated email address for queries•Website with frequently asked questions generated from phone and email queries