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Infection Prevention and ControlInfection Prevention and ControlIn Accreditation Canada’s Qmentum Program
September 2011In Accreditation Canada’s Qmentum Program
September 2011
© Accreditation Canada/Agrément Canada
BiographieBiographie
Lucie Tremblay, inf., M.Sc., Adm. A., CHE Directrice des Soins infirmiers et des Services cliniques, Centre gériatrique Maimonides Donald‐Berman. Jewish Eldercare Centre
Lucie Tremblay est directrice des soins infirmiers et services cliniques au Centre gériatrique Maimonides Donald‐Berman affilié à lʹuniversité McGill où elle détient un poste conjoint. Elle est conférencière invitée tant à lʹécole des soins infirmiers quʹàlʹécole du service social. Elle supervise les étudiants de cette université. Elle est aussi directrice des soins infirmiers et services spécialisés (intérim) au CHSLD juif de Montréal. Elle a, au cours de sa carrière, occupé différentes fonctions dans des établissements de soins de longue durée. Son implication auprès des personnes âgées lʹon amenée à publier un certain nombre dʹarticles et de faire plusieurs présentations sur des moyens pour améliorer la qualité de vie des personnes âgées vivant en institution. Elle a obtenu un DEC en soins infirmiers en 1984. Elle détient un Baccalauréat en sciences obtenu en 1988 et maîtrise en administration des services de santé obtenue en 1992. Elle détient le titre professionnel CHE obtenu en 2003 (Certified Health Executive) du Collège canadien des Leaders en Santé. En 2007, elle a obtenu le prix du ʺprofessionnel de lʹannéeʺ de lʹAssociation <Jewish Aging Services of North America>, en 2008 elle a obtenu le prix Florence pour l’excellence des soins de l’ordre des infirmières et infirmiers du Québec et en juin 2011 elle a obtenu le prix « Nursing Leadership Award » du Collège Canadien des Leaders en santé. Lucie Tremblay siège au comité de recherche du Centre gériatrique Maimonides, groupe affilié au réseau Solidage (McGill University‐Université de Montréal Research Group on Integrated Services for Older Persons).
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Presentation OutlinePresentation Outline
Accreditation Canada’s Qmentum Program Infection Prevention and Control in Qmentum
Standards Required Organizational Practices Performance Measures
Results from Canadian Health Care Organizations
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Accreditation CanadaAccreditation Canada
Major national accreditation body for organizations across all health sectors in Canada An independent, non-governmental, non-profit
organization Accredited by the International Society for Quality
in Healthcare - 2006
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Accreditation Canada’s Qmentum ProgramAccreditation Canada’s Qmentum Program
In 2008, Accreditation Canada introduced a new accreditation program called Qmentum 3 year cycle, onsite visit by peer surveyors Involves examining everyday activities and services
against standards of excellence
SERVICE EXCELLENCECustomized as required for specific sectors, services,
and markets
STANDARDS AREAS
CLIENT EXPERIENCE
08/10
EFFECTIVE ORGANIZATION
SUSTAINABLE GOVERNANCE
TM
MC
POPULATIONS (used by regions)
• Cancer• Child/Youth • Chronic Conditions
• Maternal/Child • Mental Health • Public Health
SECTORS and SERVICES
• Acquired Brain Injury• Ambulatory Care• Assisted Reproductive Technology • Blood and Transfusion• Cancer Care and Oncology • Case Management• Child Welfare • Community Health• Critical Care • Developmental Disabilities • Diagnostic Imaging• Emergency Department• Emergency Medical Services• Home Care• Hospice Palliative and End of Life• Infection Prevention and Control
• Laboratory • Long Term Care• Managing Medications • Medicine• Mental Health • Obstetrics/Perinatal Care• Operating Rooms• Organ and Tissue Donation and Transplant• Point-of-Care Testing• Primary Care• Rehabilitation • Reprocessing and Sterilization• Staffing Agencies• Substance Abuse and Problem Gambling• Surgical Care• Telehealth
CUSTOM MARKETS
• Aboriginal Health Services• Corrections Canada
• Primary Health• Stroke
• Sterilization
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Infection Prevention and Control StandardsInfection Prevention and Control Standards
Based on research and best practice information in the field, and national standards
Canadian Standards Association (CSA)
Public Health Agency of Canada (PHAC)
Community and Hospital Infection Control Association-Canada (CHICA-Canada)
Measures compliance against standards of excellence, Required Organizational Practices, and indicators
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Infection Prevention and Control Standards (cont’d)Infection Prevention and Control Standards (cont’d)
Investing in infection prevention and control Monitoring trends in infections Establishing linkages with other organizations and the community Using research, evidence, and best practice information Maintaining infection prevention and control policies and
procedures Keeping people safe from infections
Educating staff, clients and families Implementing a comprehensive hand hygiene strategy Preventing contamination of food, linen, equipment, devices, and
supplies Identifying, managing, and controlling infections
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Infection Prevention and Control Standards (cont’d)Infection Prevention and Control Standards (cont’d)
Providing a safe and suitable environment
Cleaning and disinfecting the physical environment Following manufacturers’ recommendations and accepted standards
of practice to clean and reprocess reusable medical devices Being prepared for outbreaks and pandemics
Implementing a coordinated approach to identify and manage outbreaks and respond to pandemics
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Required Organizational PracticesRequired Organizational Practices
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Required Organizational Practices (cont’d)Required Organizational Practices (cont’d)
List of Required Organizational Practices (ROPs) in the area of infection prevention and control Hand hygiene education and training Hand hygiene audit Infection control guidelines Infection rates Influenza vaccine Pneumococcal vaccine Sterilization processes
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Performance MeasuresPerformance Measures
Organizations collect infection control indicators to aid in their quality improvement initiatives Health Care Associated Infection MRSA infection rate C. difficile infection rate
Surgical Site Infection Post surgical infections rate Timely administration of prophylactic antibiotic rate
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Results from Canadian Health Care OrganizationsResults from Canadian Health Care Organizations
Required Organizational Practice 2008 Met (%)
2009Met (%)
Hand hygiene education and training 94 97
Hand hygiene audit n/a 72
Infection control guidelines 91 97
Infection rates 63 76
Influenza vaccine 86 92
Pneumococcal vaccine 93 91
Sterilization processes 88 87
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Results from Canadian Health Care Organizations (cont’d)Results from Canadian Health Care Organizations (cont’d)
Strengths Implementing policies and procedures in line with
international, federal, and provincial/territorial infection control guidelines
Providing access to alcohol-based hand rubs at the point-of-care and service delivery
Delivering hand hygiene education and training Opportunities for Improvement
Monitoring compliance with hand hygiene practices and using the results to make improvements
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Next StepsNext Steps
Continuing to enhance Qmentum standards, ROPsand performance measures in the area of patient safety Continuing to share results with partners and
stakeholders across Canada to improve the safety and quality of health care services for patients and their families