Accreditation

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Who do you want to accredit?

A.  The hospital as a whole – with regard to infec=on control

B.  The Infec=on Control unit

Both works – depending on how broad you evaluate the seFng in which the IC unit operates

Na=onal IC guidelines Norm with regard to size and structure of IC units

¤ Na=onal IC guidelines ¤ Norm with regard to size and structure of IC units ¤ Recognized training for ICP & MD’s ¤  Laws with regard to CME ¤  Laws with regard to transmissible diseases ¤  Inspectorate

² An authority that can penalize non-‐conforming healthcare ins=tu=ons

¤ Risk of acquiring preventable infec=ons due to breaks in preven=ve measures ² Guidelines implementa=on & behavioral change

¤ An=microbial resistance impeding pa=ent’s safety ² Interrupt transmission of MDROs ² An=microbial stewardship

Indicators need to asses the above!

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¤ Structure

¤ Process

¤ Outcome

¤ to ensure that the infec=on control team is geFng the necessary funding to adequately do their work in a seFng that commits to pa=ents safety aspects

Important indicator, but ² Par=cular considera=on needed ² Major piXalls -‐ weighing of individual steps of the process. •  “A chain is only as strong as it’s weakest link” is not correct for many processes!

Process if okay, but outcome is what it’s all about

¤  Incidence of defined MDRO in blood-‐cultures per 100,000 days at risk ² Overall admisson days of the hospital -‐ (2 x admissions)

¤  Environmental cleaning ²  final cleaning a`er discharge of isola=on pa=ent check with microbiology or ATP

¤ Hand hygiene ² WHO method or compliance rate

Please – No more!

Medicine 2015 Paper work instead of work with pa=ents

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¤  Easy to collect ²  Extractable from LIS and HIS ²  App support

¤  Clearly and well defined ²  Everyone really measuring the same, comparable between different hospitals

¤  Immediately accessible for the user ²  Guide interven=ons

Do not allow non-professionals to formulate them ��

MD*

*lead

ICP ICP

ICT

Inspec- ��torate

Willemsen et al Antmicrob Resistance Infect Control 2014;3:26

Crosssec8onal surveillance of: ¤  Two outcome variables:

² Prevalence of HAI (SSI, LRTI, UTI, GI, bacterial conjunc=vi=s) ² prevalence of rectal carriage of ESBL producing Enterobacteriacea

¤  Two resident-‐related risk factors: ² prevalence of medical device ² prevalence of an=microbial therapy

¤  Three ward-‐related risk factors: ² environmental contamina=on ² shortcomings in infec=on preven=on precondi=ons ² availability of local infec=on preven=on guidelines


¤  For each outcome variable or risk factor, breakpoints were set to make the division in 3 categories ²  low, intermediate and high

²  Classifica=on based on na=onal prevalence surveys, scien=fic publica=ons and if no data was available on expert opinion

¤  Popula=on characteris=cs get considered Willemsen et al Antmicrob Resistance Infect Control 2014;3:26 Willemsen et al Antmicrob Resistance Infect Control 2014;3:26

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¤  Infec=ons in NH ¤  Intravenous administra=on ¤  Medicine administra=on ¤  Cleaning/disinfec=on and

steriliza=on ¤  Storage of sterile materials ¤  Waste collec=on and transport ¤  Urine drainage and defeca=on ¤  Care of airways ¤  Wound care ¤  Tube feeding

¤  MDRO/MRSA ¤  Norovirus ¤  Scabies ¤  Legionella control ¤  Food safety ¤  Pets in the NH ¤  Registra=on of ID ¤  Hand hygiëne ¤  PPE ¤  Personal hygiene ¤  Personnel ID & blood exp


¤  Bathroom sink ¤  Bedside cabinet ¤  Table living room ¤  Microwave kitchen ¤  Bedside commode ¤  U=lity room ¤  Sterile storage shelve ¤  Toilet seat ¤  Washing bowl Willemsen et al Antmicrob Resistance Infect Control 2014;3:26

¤  Availability of hand alcohol ¤  Availability of gloves, gowns, masks ¤  Availability of needle container ¤  Availability of bedpan washer ¤  Availability of plas=c aprons ¤  Presence of at least one HH sink per 15 residents ¤  Presence of at least wo toilet groups per 15 residents ¤  Presence of at least one single room with bathroom per 15 residents

Willemsen et al Antmicrob Resistance Infect Control 2014;3:26 Willemsen et al Antmicrob Resistance Infect Control 2014;3:26


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Dutch Society of ICP

Dutch Society of Medical Microbiology

Quality & Visita8on commiEee (2006)

¤  Aiming at the work of the infec=on control team/unit – not the hospital as a whole

¤  Audits are done by ICPs and IC-‐MDs ¤  The audit is based on interna=onal and na=onal laws and guidelines, including ISO 14001 and OHSAS 18001

¤  Uses Plan-‐Do-‐Check-‐Act (PDCA) principles

The quality criteria are defined as: ¤  Norms = must haves ¤  Points of anen=on( POA) = the minimum norms (checkable via quick-‐scan)

¤  Addi=onal points = want to haves

1.  Mission and vison 2.  Strategy & Aims 3.  Work of the IC unit 4.  Human resource aspects 5.  Finances 6.  Housing 7.  Internal Quality Control

Norm ¤ Unit has a vision and mission POA ¤ Present on paper ¤ Only one vision and mission ¤ Concurrent with hospital V&M ¤ The ambi=on formed by V&M should be known to others

¤  Quality system ¤  Strategy planning & report

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Norm ¤ Quality system designed, documented and implemented

PAO ¤ Complete Quality Manual ¤ Inten=on to cooperate documented ¤ Scope defined ¤ Responsibili=es of controlling groups documented

Norm ¤ Strategy and according aims are formulated and supported (FTE, $)

¤ Responsibili=es formulated POA ¤ Mul=-‐year strategy plan present ¤ Year plan present

² SMART-‐formulated ² corresponding with mul=-‐year plan ² Controlled planning and achievements ² Safety, integrity, privacy, communica=on

Norm ¤ Clear descrip=on of responsibili=es and what the unit is doing

POA ¤ What are the primary tasks – documented ¤ “Customers” know what the tasks are ¤ Tasks are priori=zed ¤ Possible overlap with technical services, cleaning, CSD, … described

I skip the next 7 slides but they are online

¤  Surveillance and implementa=on of improvement IC guidelines based on na=onal laws/guidelines

¤ Outbreak management ¤  Training ¤ Audits ¤ Consultancy ¤ Cleaning, disinfec=on, steriliza=on ¤ Construc=on ¤ Control of water and air ¤ Buying of disposables & othet biomedical products ¤ Research

Norm ¤  Posi=on and hirachical and func=on management of units is described

POA ¤ Organogram present ¤ SLA with external organisa=ons ¤ Par=cipa=on in comminees (internal & extermal) ¤ Communica=on and exchange of informa=on with microbiology lab

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1.  Mission and vison 2.  Strategy & Aims 3.  Work of the IC unit 4.  Human resource aspects 5.  Finances 6.  Housing 7.  Goods 8.  Internal Quality Control

¤ Internal structure and responsibility ¤ Descrip=on of the professional func=ons ¤ Overview of individuals tasks and addi=onal/external work

¤ Planning (free, on-‐duty, …) including con=nuity in the work and communica=on/reachability

¤ SOPs ² New co-‐worker, (cont.) eductaion/training, size of the unit, guidline with regard to part-‐=me work, …

¤ Yearly professional evalua=on of each co-‐worker

¤  Independence of the unit ¤  Document who is responsible for finances – budget control

¤  Contracts and SLAs ¤  Insurances

¤  Close to wards ¤  Adequate rooms

² including telephones, computers, printers, …

¤  Access to all systems (LIS, HIS, OR ystem, …) ¤  Safety aspects

¤  Documents and archives ¤  Internal and external quality control of the unit ¤  Management review

¤  Lots of good stuff, and probably needed for an accredita=on, best we have, but …

¤  Very theore=cal Long and a lot of work ¤  Addi=onal to professional audit by peers – instead of integrated

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We can’t make it fun, but we do our best to make it prac=cal and easy

Health & Medicine

Accreditation