A Crosswalk Between The Regulatory Alphabet

SoupMeeting CMS Conditions of Participation (COPs) and

Interpretive Guidelines and JCAHO Standards and Elements

of Performance (EPs)9/13/05 Carolyn Fiutem, MT, CLS, CIC

Consistency in Both Camps

Both address organization and policies

Both address responsibilities of leadership

Both emphasize upstream solutions Both emphasize house-wide

implementation Wording different but principles are

the same, few exceptions

Program Comparisons

CMS COPs have 2 standards

1st affects organization and policies

2nd affects responsibilities of CEO, Medical Staff & DONs

JCAHO has 2 focuses

IC.1.10-6.10 focuses on IC programs & its components

IC.7.10-9.10 focuses on structure and resources

Expanded Guidelines/New Standards

Coordinate with hospital leadership to include all hospital staff, contract workers, and volunteers in infection surveillance and reporting

Incorporate antibiotic resistant/emerging infection surveillance in IC Program

Coordinate with hospital leadership/public health authorities for emergency preparedness

Examine surveillance methodologies for outpatient/short-stay surgical site infections

Compare and Contrast

Tag A-0338 CoP 482.42 – Sanitary Environment and Active Program

Clutter, filth, unappealing odors

Method for monitoring housekeeping, maintenance and other activities

IC.1.10 Coordinated process

Is the entire organization on board and integrated into the IC program?

Does the program share data and information? With whom and how?

Compare and contrast (cont)

482.42 CoP cont. How are patients/

HCWs educated? Who conducts

training/how evaluated?

Employee health – policies, illness monitoring and screening protocols

How is aseptic technique monitored?

IC.1.10 cont How do I

communicate with those who need to know? Is there a plan? System for notifying about HAI after patient leaves or when patient just admitted from another facility?

Does the program have a workable, dynamic IC plan with required elements?

Compare and Contrast (cont)

CoP 482.42 cont. Systems to ID and

assess patients/HCWs at risk

Specific measures of prevention, early detection, control, education, investigation

Evaluated, reviewed, revised

IC.5.10 Evaluate effectiveness of IC processes & strategies

Are evaluations performed in a timely fashion?

Is the process easy to understand?

Data presentation verbal and charts/graphs?

Solutions proposed?

Compare and Contrast (cont)

CoP 482.42 cont. Procedures for

working with local, state, federal health authorities in an emergency

P/P developed in coordination with federal, state and local emergency preparedness and health authorities to address communicable disease threats and outbreaks

IC.6.10 Emergency Preparedness

Did IC have input into emergency plan?

Does it address IC issues in enough detail to be useful?

Has IC worked with the community for designing response to large influx?

Can ED/staff verbalize their role in prevention/control during an emergency?

Compare and Contrast (cont.)

CoP 482.42 cont. The hospital’s IC program must

be integrated into its hospital-wide QAPI program.

PI.1.10 Collects data to monitor performance

16. IC surveillance and reporting

Compare and Contrast (cont)

CoP 482.42 cont. Orientation of all new hospital

personnel to infections, communicable diseases and the IC program

HR.2.10 Orientation for initial job training and information

Specific job duties and responsibilities and unit, setting or program-specific job duties and responsibilities related to safety and infection control

Compare and Contrast (cont)

CoP 482.42 cont. The hospital must provide a sanitary

environment to avoid sources and transmission of infections and communicable diseases.

EC.7.10 Manage utility risks The hospital designs, installs and

maintains ventilation equipment to provide appropriate pressures, air-exchanges and filtration efficiencies to control airborne contaminants

Compare and Contrast (cont)

Tag A-0339 CoP 482.42(a) The hospital must

designate in writing an individual or group, qualified through education, training, experience, AND certification or licensure as IC officers.

IC.7.10 IC program is managed effectively.

Hospital assigns responsibility for IC program activities based on goals and objectives

Qualifications may be met thru ongoing education, training, experience AND/OR certification

Compare and Contrast (cont)

482.42(a) cont. IC officer(s) must

develop and implement polices governing the control of infections and communicable diseases

IC.7.10 cont. Individual(s)

coordinates all infection prevention and control activities

Facilitates ongoing monitoring of the effectiveness of prevention/control activities and interventions

IC.4.10 Implement Strategies

7 required core interventions/strategies 1. Organization-wide hand hygiene 2. Reduce risk of infections related to

procedures, medical equipment and devices 3. Reduce potential for transmission 4. Screen LIPs, staff, students/trainees,

volunteers for vaccine preventable diseases 5. Referrals for assessment, testing,

immunization for those w/ infectious diseases 6. Referrals for assessment, testing,

immunization for those exposed 7. Animals in the health-care organization

IC.4.10 Cont.

Have all 7 strategies been addressed in the IC plan?

Reviewed by a multi-disciplinary team?

Leadership approved and committed resources?

Compare and Contrast (cont)

Tag A-0340 CoP 482.42(a)(1) Develop system for

identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.

IC.2.10 Identifies risks for the acquisition and transmission of infectious agents on an ongoing basis.

IC.3.10 Risks determine priorities and goals

Compare and Contrast (cont)

CoP482.42(a)(1) cont

System for identifying, investigating, reporting and preventing spread among patients, and hospital personnel including contract staff and volunteers, especially those occurring in clusters

IC.2.10 (cont) Surveillance

activities to ID infection prevention and control risks pertaining to patients, LIPs, staff, volunteers, and students/trainees, visitors and families, as warranted

IC.2.10 (cont)

IC risk assessment been performed to establish priorities?

Key staff participated? A consistent template used? Clear priorities? Leadership supportive? Have results been distributed? APIC/JCAHO to develop resource

book w/ templates

IC.3.10 (cont)

Are goals based on ICRA priorities? Number of goals correspond with available

resources? (Note: Many goals specified by CMS interpretive guidelines.)

Are the required goals included? (JCAHO, CMS, OSHA etc)

Specific measurable objectives for each goal?

Leadership approved of goals and objectives and committed resources and other support?

Example

Priority from ICRA – Hospital scores in upper quartile of NNIS data for VAPs in ICUs

JCAHO required goal – Minimize risk associated with procedures, medical equipment, and medical devices

Organizational Goal – Reduce Ventilator Associated Pneumonias

Objective – Reduce VAPs in Medical and Surgical ICUs by at least 10% by December 2006

Strategy – Use VAP bundle and implement all evidence-based procedures to minimize VAPs

Tag A-0341 CoP 482.42(a)(2)

No corresponding JCAHO standard/EP Maintain a log of all incidents related to

infections and communicable diseases Includes employee health Not just nosocomial infections Includes infections/communicable diseases

of patients and all staff (pt care, non-pt care, contract, volunteers)

Includes post-op infections in IPs who are D/C soon after surgery or outpatient surgery pts

APIC/CMS working on rewording this CoP and deleting the word “ALL” before incidents

Compare and Contrast (cont)

Tag A-0342 CoP 482.42(b) Responsibilities of

CEO, DON and Medical Staff

In-service training for IC problems

Implementing corrective action

Evaluate effectiveness

Document corrective actions and outcomes

IC.8.10 IC.8.10 Collaboration with IC Collaboration with IC programprogram

Are there multi-Are there multi-disciplinary projects disciplinary projects to help with the IC to help with the IC program?program?

IC.9.10 Resource IC.9.10 Resource AllocationAllocation

Can the IC team Can the IC team make the business make the business case to leadership case to leadership for a strong IC for a strong IC program?program?

Making the Business Case

IC is patient safety. IC good for the patient, physicians,

staff, visitors, families, volunteers. IC improves quality. IC reduces risk. IC protects the image of the

hospital. IC saves money!

IC and EC overlap

Construction and ICRAsConstruction and ICRAs Facility cleanliness and maintenanceFacility cleanliness and maintenance Hand hygiene Hand hygiene SharpsSharps SpillsSpills Sterilization and disinfectionSterilization and disinfection Sink placementSink placement Utilities – Air and waterUtilities – Air and water Equipment Management – biomed, Equipment Management – biomed,

SPDSPD

JCAHO take home messages

Written plan – updatedWritten plan – updated Continual risk assessmentsContinual risk assessments Multi-disciplinary/collaborativeMulti-disciplinary/collaborative Qualified staffQualified staff TracersTracers Environment of careEnvironment of care Integration into safety and quality Integration into safety and quality

programsprograms Use data to demonstrate improvementUse data to demonstrate improvement IC National Patient Safety GoalsIC National Patient Safety Goals

CMS take home message

Survey request list:Survey request list: Organizational chartOrganizational chart IC manualIC manual IC meeting minutesIC meeting minutes Log of infections/communicable Log of infections/communicable

diseasesdiseases Policies and proceduresPolicies and procedures Reporting and monitoring systemsReporting and monitoring systems Surveillance planSurveillance plan Emergency preparedness Emergency preparedness

documentationdocumentation

CMS message cont.

Focus areas: (Follow all CDC guidelines) Transmission-based precautions Surgical Services Food service Off-site locations Medical Records – recording of HAIs (ID, Doc,

Intervention, Tx) BBPs Hand Hygiene – 1 is a deficiency! Employee knowledge – “Tell me about…” BSIs Antibiotic Prophylaxis Protocol Campaign to Save 100,000 Lives

Thank You and Questions?