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Administrator
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Registered: ‎02-22-2010
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Joint Commission for IP Webinar

[ Edited ]

Thanks for joining our presentation with Brenda Helms, "Joint Commission Readiness for Infection Control."


View the on-demand recording, download the slides and the risk assessment form.

 

How are you preparing for your TJC survey? Do you have a question for Brenda? Post it here and she will be answering for a limited period of time.

Administrator
Posts: 578
Registered: ‎02-22-2010
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Re: Joint Commission for IP Webinar

Here are some questions from our live presentation:

 

Have you heard any concerns with utilizing modified contact precautions for behavioral health units?

 

How do you ensure that infection prevention education is spread to physicians and LIPs in your setting?

 

How do you measure hand hygiene compliance in your setting?

 

Can you elaborate some more about the active desktop for Infection Control?

 

Our acute care VA medical center includes acute care as well as outpatient care. Are werequired to have a separate ambulatory care risk assessment in addition to the hospital wide RA? (We also have RA for Beh Health, HBPC, and CLC)                                                

 

What, if any financial penalties might be associated with non-compliance to recommended guidelines, either presently or in the future?

Expert
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Registered: ‎03-31-2011
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Re: Joint Commission for IP Webinar

Have you heard any concerns with utilizing modified contact precautions for behavioral health units?

No I have not heard any concerns regarding modified contact precautions for behavioral units.  That is a very unique environment and in some instances standard contact precautions can have an adverse effect on the patient.

 

How do you ensure that infection prevention education is spread to physicians and LIPs in your setting?

I attend the Medical Executive Committee meetings and the section meetings (Surgery, Cardiovascular, etc) to provide information to the physicians.

How do you measure hand hygiene compliance in your setting?

we have secret shoppers who do direct observation.  We change the secret shoppers periodically so that they remain secret.  The managers also perform hand hygiene audits.  We prefer that the auditors audit somewhere other than their own unit.

Can you elaborate some more about the active desktop for Infection Control?

When you sign on to any of our computers you see the desktop.  We have placed drop down menus for different items such as Infection Control, Quality and Education.  When you pull down the drop down you have choices to click on for either monthly reports, interesting articles etc.

Our acute care VA medical center includes acute care as well as outpatient care. Are werequired to have a separate ambulatory care risk assessment in addition to the hospital wide RA? (We also have RA for Beh Health, HBPC, and CLC)  

If they are under the same license you do not.  You just need to make sure that all are areas are covered.  If they are at a different site it would be wise to make sure that you have a copy of the risk assessment and plan available at each site.

What, if any financial penalties might be associated with non-compliance to recommended guidelines, either presently or in the future?

The penalties that I am aware of are centered mainly around reimbursement.  CMS will no longer pay for never events and if you do not meet certain criteria on SCIP measures or other CORE Measures it will decrease your reimbursement from CMS by a certain percentage.

 

Administrator
Posts: 578
Registered: ‎02-22-2010
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Re: Joint Commission for IP Webinar

Here are some other questions from our live presentation:

 

You mentioned doing screening and surveillance for MRSA upon patient admission. This has been a somewhat controversial practice. Can you comment on the value you see with this process and the benefits you have gained?

 

Have you been able to track the impact of specific infection prevention strategies on incidence rates for infections? If so, do you know what specific strategies or process improvements have made the most impact?

 

What do you know about "gel" nails?  Is this an acceptable gel polish product or is this an artificial nail?

 

How do you deal with alert fatigue?

 

Are there any resources available to specifically Home Health?

 

Does your facility require written documentation from your physicians and volunteers that their immunizations are in compliance?

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Expert
Posts: 2
Registered: ‎03-31-2011

Re: Joint Commission for IP Webinar

You mentioned doing screening and surveillance for MRSA upon patient admission. This has been a somewhat controversial practice. Can you comment on the value you see with this process and the benefits you have gained?

We implemented this practice shortly after opening our hospital so as far as improvements in rates I cannot show that.  However, I feel that by identifiying these patients early on we can get them in isolation quicker as well as give the surgeons the opportunity to decolonize if they choose to.  Our MRSA rates are 0.04/1000 patient days.

 

Have you been able to track the impact of specific infection prevention strategies on incidence rates for infections? If so, do you know what specific strategies or process improvements have made the most impact?

We developed a foley care bundle for foley insertion as well as daily care of the foley that brought our CAUTI rates from 5 down to 2/1000 catheter days.  We have had several months that our rate was zero since implementing the bundle.

Our hand hygiene compliance was at 70% and after implementing an accountability program our compliance rates remain around 95%.  we have also noted that the months that the hand hygiene compliance rate is down our infection rates seem to go up.

We were having a problem with CLBSI on one floor and by implementing rounding to check all dressings daily and use of a dressing change checklist we were able to decrease the rate of CLBSI to zero.

 

What do you know about "gel" nails?  Is this an acceptable gel polish product or is this an artificial nail?

Gel nails are the same product as artificial nails.  They have to be taken off by a salon and do create an artificial layer that is dried on by UV lights.  We include gel nails in with artificial nails and they are not allowed.

 

How do you deal with alert fatigue?

I am assuming that you mean all the alerts from TJC, CDC, DSHS, CMS etc.  What I do is skim the alert when it first comes across email to see if it is something that needs my immediate attention.  If it is not I save it for when I go home to thoroughly read it to decide what if any implications it has for my facility.  Although I do not advocate taking work home with you this seems to be the only way that I can have quiet time to read the alerts without interruption.

 

Are there any resources available to specifically Home Health?

TJC and CMS both have requirements and conditions of participation that are specific for Home Health.

 

Does your facility require written documentation from your physicians and volunteers that their immunizations are in compliance?

Yes.  The volunteers actually have to complete an employee heatlh pre-hire screening just like the employees do.  If they do not have documentation of their TB skin testing they receive it from us.  The physicians are required through credentialing to provide their immunization records including TB skin testing and again every they go through re-credentialing.  Their records are maintained in the Medical Staffing Office once they are cleared through employee health.