Transcription
CMS and JointCommissionKaren K Hoffmann RN MS CIC FSHEA FAPIC
DisclaimerThe views and opinions expressed in thislecture are those of this speaker and do notreflect the official policy or position of anyagency of the U.S. government.
Objectives1. Discuss the CMS Hospital Conditions ofParticipation (CoPs)2. Discuss the CMS revised infection controlworksheet and survey process3. CMS TJC Crosswalk4. Other initiatives related to HAI reduction
Organization of SCGDivision of Acute Care Services (DACS) Acute Care Hospitals, LTACs, CAHs, ASCs, Rehab,PsychiatricDivision of Nursing Homes (DNH) Nursing HomesDivision of Continuing Care Providers (DCCP) Home Health and Hospice, ESRD, PsychiatricResidential Treatment FacilitiesClinical Laboratory Improvement Amendments (CLIA)
CMS Survey and Certification Group(SCG) StructureFederalCMS Headquarters -------AOs10 Regional ation/RegionalOffices/RegionalMap.htmlState Agencies
Where to Submit a Question orInquiry?Division of Acute Care Services (DACS)PFP.SCG@cms.hhs.govDivision of Nursing Homes (DNHs)DNH TriageTeam@cms.hhs.govESRD Survey & Certification GroupESRDSurvey@cms.hhs.govFind resources for compliance with the ESRD Conditions for ions/05 Dialysis.aspSCG General enInfo/
CMS Conditions of Participation (CoPs) &Conditions for Coverage (CfCs)CMS develops CoPs - (hospitals, CAHs,ASCs)CfCs - (ESRD, LTC/NH, ASCs)Minimum health and safety standards that providersand suppliers must meet in order to be Medicare andMedicaid certified and receive reimbursement.The Interpretive Guidelines (IGs)provide instructions tothe surveyors on how to survey the CoP. Note: key are“should” versus “must” statementscms.gov
CMS Hospital Infection ControlConditions of Participation (CoPs)o Provide a sanitary environment and have an active program forprevention, control, investigation of infections/communicable diseases(A-0747)o Have a designated person(s) as infection control officer(s) to developand implement policies (A-0748)o Infection control officer(s) must develop a system for identifying,reporting, investigating and controlling infections/communicabledisease of patients/personnel (A-0749)o CEO, medical staff, and Director of Nursing must (A-0756) Ensure hospital-wide QAPI and training programs address problemsidentified by IPs Be responsible for implementation of successful corrective actionplans
CMS Hospital InterpretiveGuidanceProgram must:o Be incorporated into hospital-wide QAPI programo Include nationally recognized practices, guidelines,and regulationso Conduct surveillance facility-wide (all locations,departments, services, campuses), follow NHSN
CMS Hospital Interpretive GuidanceProgram must: Appropriately monitor housekeeping, maintenance,and other activities to ensure sanitary environment Have active surveillance component covering patientsand personnel Develop and implement IC interventions to addressissues identified through detection, and monitoreffectiveness of interventions
CMS Hospital InterpretiveGuidance – Organizational Policies Designate in writing infection control officer(s) Must be qualified No specification on number of IPs or hours Develop and implement policies governing control ofinfections/communicable disease
CMS Hospital Interpretive GuidanceIP(s) mustDevelop and implement infection control measures for HCPsMitigate risk (POA and HAI)Active surveillanceMonitor compliance with policy and proceduresProgram evaluation and revisionReport communicable diseasesMaintain sanitary physical environment
Notice of Proposed Rule Making (NPRM) Hospital andCAH Changes to Promote Innovation, Flexibility, andImprovement in Patient Care, 2016Hospital-wide IPC and antibiotic stewardship programs(ASP);Designate leaders of the IPCP and the ASP respectively,who are qualified through education, training, experience,or certification.Quality Assessment and Performance Improvement(QAPI) program incorporate quality indicator data relatedto hospital readmissions and hospital-acquired conditions;Competencies documented for IPC trainingAssess for IPC during Transitions of Care
NC Rules for Licensing Hospitals –Section .5100 – Infection ControlInfection Control Committee required to meet at leastquarterlyAll policies and procedures must be reviewed at leastevery three yearsExcept Exposure Control Plan and Infection ControlPlan (Annual)
Infection ControlWorksheet
CMS ICW StructureModule 1 – Infection Control/PreventionProgramModule 2 – General Infection ControlElementsModule 3 – Equipment ReprocessingModule 4 – Patient TracersModule 5 – Special Care Environments
Module 1 ElementsSection 1.A. – Infection control/prevention programand resourcesSection 1.B. – Hospital QAPI systems re: InfectionPrevention and ControlSection 1.C. – Systems to prevent transmission ofMDROs and promote antibiotic stewardship,surveillanceSection 1.D. – Personnel education system/IC training
Module 2 ElementsSection 2.A. – Hand HygieneSection 2.B. – Injection Practices and Sharps Safety(Medications, Saline, Other Infusates)Section 2.C. – Personal ProtectiveEquipment/Standard PrecautionsSection 2.D. – Environmental Services
Module 3 ElementsSection 3.A. – Reprocessing of Semi-Critical EquipmentSection 3.B. – Reprocessing of Critical Equipment,Sterilization of Reusable Instruments and DevicesSection 3.C – Single-Use Devices (SUDs)
Module 4 ElementsSection 4.A. – Urinary Catheter TracerSection 4.B. – Central Venous Catheter TracerSection 4.C. – Ventilator/Respiratory Therapy TracerSection 4.D. – Spinal Injection ProceduresSection 4.E. – Point of Care DevicesSection 4.F. – Isolation: Contact PrecautionsSection 4.G. – Isolation: Droplet PrecautionsSection 4.H. – Isolation: Airborne PrecautionsSection 4.I. – Surgical Procedure Tracer
Using Worksheet for Self-AssessmentCoPs set minimum standardWorksheet also includes best practiceRecommendations that are not scoredThis version of worksheet is “ideal” self assessmenttoolFinal version will change to accommodate surveyorneeds
CMS – JointCommissionCrosswalk
TJC ScoringElements of Performance (EPs) are scored on a 3-point scale:0 insufficient compliance1 partial compliance2 satisfactory complianceEPs are divided into two scoring categoriesA – Structural, NPSGs, CoPs (scored as 0 or 2)C – Scored based on number of found deficiencies2 one or no occurrences of noncompliance1 two occurrences0 three occurrencesAll 0s and 1s have to be addressed by Evidence of StandardsCompliance (ESC) submissions
Chapter OutlinePLANNING (IC.01)IMPLEMENTATION (IC.02)Responsibility (IC.01.01.01)Plan .05.01)InfluxMedical Equipment, Devices,Supplies (IC.02.02.01)Transmission of Infections(IC.02.03.01)Influenza Vaccinations(IC.02.04.01)(IC.01.06.01)Evaluation and Improvement(IC.03.01.01)
Crosswalk for Tag A-0747CMSTJC STANDARDSA-0747EC.02.05.01 – Hospitalmanages risk associated with itsutility systems.Hospital must provide asanitary environment toavoid sources andtransmission ofinfections/CD. There mustbe an active program forthe prevention, control andinvestigation ofinfections/CD.EP 1 – Designs and installs utilitysystems hat meet patient care andoperational needs.EP 5 – Minimizes pathogenicbiological agents in cooling towers,domestic water systems, and otheraerosolizing water systemsEP 6 – In areas designed to controlairborne contaminates, theventilation system providesappropriate pressure relationships,air-exchange rates, and filtration
Crosswalk for Tag A-0747CMSTJC STANDARDSA-0747Hospital must provide asanitary environment toavoid sources andtransmission ofinfections/CD. There must bean active program for theprevention, control andinvestigation ofinfections/CD.EC.02.05.05 –Hospital inspects test, andmaintains utility systemsEP 4 – Hospital inspects, testand maintains the following:infection control utility systemcomponents on the inventory.Activities are documented
Crosswalk for Tag A-0747CMSTJC STANDARDSA-0747EC.02.06.01 – Hospital establishesHospital must provide asanitary environment toavoid sources andtransmission ofinfections/CD. There must bean active program for theprevention, control andinvestigation ofinfections/CD.and maintains a safe, functionalenvironmentEP 13 – Hospital maintainsventilation, temperature, andhumditiy levels suitable for thecare, treatment and servicesprovidedEP 20 – Areas used bypatients are clean and free ofoffensive odors
Crosswalk for Tag A-0747CMSA-0747Hospital must provide asanitary environment toavoid sources andtransmission ofinfections/CD. There must bean active program for theprevention, control andinvestigation ofinfections/CD.TJC STANDARDSEC.02.06.05 – Hospital managesits environment duringdemolition, renovation, and newconstruction to reduce the riskto those in the organizationEP 2 – When planning fordemolition, construction, orrenovation, the hospital conductsa preconstruction riskassessment for air quality,infection control, utility systems,noise, vibration, and otherhazards that affect careEP 3 – The hospital takes actionsbased on its assessment tominimize risk during demolition,construction and renovation
Crosswalk for Tag A-0747CMSA-0747Hospital must provide asanitary environment toavoid sources andtransmission ofinfections/CD. There must bean active program for theprevention, control andinvestigation ofinfections/CD.TJC STANDARDSIC.01.02.01 – Hospital leadersallocate needed resources for ICprogramEP 1 – Provides access toinformationEP 2 – Provides laboratoryresourcesEP 3 – Provides equipmentand supplies
Crosswalk for Tag A-0747CMSA-0747Hospital must provide asanitary environment toavoid sources andtransmission ofinfections/CD. There must bean active program for theprevention, control andinvestigation ofinfections/CD.TJC STANDARDSIC.01.03.01 – Hospitalidentifies risk for acquiringand transmitting infectionsEP 1 – identifies risk foracquiring and transmittinginfections based on: itsgeographic location, community,and population servedEP2 – IDs risk based on: Thecare treatment and services itprovidesEP 3 – IDs risk based on: analysisof surveillance activities andother IC activitiesEP 4 – Reviews and identifies itsrisk at least annually andwhenever significant changesoccur with input from IPs,medical staff, nursing, leadership
Crosswalk for Tag A-0747CMSA-0747Hospital must provide asanitary environment toavoid sources andtransmission ofinfections/CD. There must bean active program for theprevention, control andinvestigation ofinfections/CD.TJC STANDARDSIC.01.05.01 – Hospital has aninfection control plan (ICP)EP 1 – When developing plan,hospital uses evidence-basednational guidelines, or expertconsensusEP 2 – ICP includes writtendescription of the activities,including surveillance, tominimize, reduce, or eliminaterisk of infectionEP 3 – ICP includesdescription of the process toevaluate ICP
Crosswalk for Tag A-0747CMSTJC STANDARDSA-0747Hospital must provide asanitary environment toavoid sources andtransmission ofinfections/CD. There must bean active program for theprevention, control andinvestigation ofinfections/CD.IC.01.05.01 – Hospital has aninfection control plan (ICP)EP 5 – describes the processfor investigating outbreaksEP 6 – All hospitalcomponents and functions areintegrated into IC activitiesEP 7 – Hospital has methodfor communicatingresponsibilities aboutpreventing and controllinginfections to LIPs, staff,visitors, patients, and families.
Crosswalk for Tag A-0747CMSTJC STANDARDSA-0747Hospital must provide asanitary environment toavoid sources andtransmission ofinfections/CD. There must bean active program for theprevention, control andinvestigation ofinfections/CD.IC.01.06.01 – Hospital preparesto respond to influx ofpotentially infectious patientsEP 4 – Hospital describes inwriting how it will respond toinflux of potentially infectiouspatientsEP 6 – When necessary,hospital activates its responseto influx of potentiallyinfectious patients
Crosswalk for Tag A-0747CMSTJC STANDARDSA-0747IC.02.01.01 – Hospitalimplements its ICPEP 1 – Hospital implements itsIC activities, includingsurveillance, to reduce risk ofinfectionEP 2 – Hospital uses StandardPrecautions to reduce the riskof infectionEP 3 – Hospital implementsTransmission-basedPrecautionsHospital must provide asanitary environment toavoid sources andtransmission ofinfections/CD. There must bean active program for theprevention, control andinvestigation ofinfections/CD.
Crosswalk for Tag A-0747CMSTJC STANDARDSA-0747IC.02.01.01 – Hospital implementsits ICPEP 5 – Investigates outbreaksEP 6 – Minimizes risk of infectionwith storing and disposing ofinfectious wasteEP 7 – Implements methods tocommunicate responsibilities forIC to LIPs, staff, visitors, patients,and familiesEP 8 – Reports infectionsurveillance, prevention, andcontrol information to theappropriate staff within hospitalHospital must provide asanitary environment toavoid sources andtransmission ofinfections/CD. There must bean active program for theprevention, control andinvestigation ofinfections/CD.
Crosswalk for Tag A-0747CMSTJC STANDARDSA-0747IC.02.02.01 – Hospital reduces therisk of infection associated withmedical equipment, devices andsuppliesEP 1 – Implements IC activitiesduring: Cleaning and low-leveldisinfectionEP 2 - Implements IC activitiesduring: intermediate and highlevel disinfection and sterilizationEP 3 – Disposing of medicalequipment, devices, suppliesEP 4 – Storing medicalequipment devices and suppliesHospital must provide a sanitaryenvironment to avoid sourcesand transmission ofinfections/CD. There must be anactive program for theprevention, control andinvestigation of infections/CD.
Crosswalk for Tag A-0747CMSTJC STANDARDSA-0747Hospital must provide asanitary environment toavoid sources andtransmission ofinfections/CD. There must bean active program for theprevention, control andinvestigation ofinfections/CD.IC.02.03.01 – Hospital works to preventtransmission of infectious disease amongpatients, LIPs, and staffEP 1 – Makes screening forexposure/immunity to Infectiousdiseases available to LIPs and staffEP 2 – Refers/provides LIPs andstaff with an infectious disease forassessment, testing,prophylaxis/treatment, andcounselingEP 3 – Refers/ providesoccupationally exposed LIPs andstaff for assessment, testing EP 4 – Patients exposed toinfectious diseases, hospitalprovides/refers for assessment,testing
Crosswalk for Tag A-0747CMSTJC STANDARDSIC.03.01.01 – Hospital evaluates theA-0747effectiveness of the IC planEP 1 – Hospital evaluates IC Planannually and whenever risk changeHospital must provide asanitary environment toEP 4 – Evaluation includes:avoid sources andimplementation of IC plantransmission ofactivitiesinfections/CD. There must beEP 6 – Findings from evaluationan active program for thecommunicated annually toprevention, control andindividuals/group that managesinvestigation ofpatient safety programinfections/CD.EP 7 – Uses findings fromevaluation if IC plan when revisingIC plan
Crosswalk for Tag A-0747CMSA-0747Hospital must provide asanitary environment toavoid sources andtransmission ofinfections/CD. There must bean active program for theprevention, control andinvestigation ofinfections/CD.TJC STANDARDSNPSG.07.01.01 – Comply withCDC or WHO hand hygieneguidelinesEP 1 – Implement program thatfollows categories 1A, 1B and 1Crecommendations
Crosswalk for Tag A-0748CMSA-0748Organization and Policies: Aperson(s) must be designatedas infection control officer(s) todevelop and implementpolicies governing control ofinfections/CD. The infectioncontrol officer(s) must developa system for identifying,reporting, investigating, andcontrolling infections/CD ofpatients and personnelTJC STANDARDSIC.01.01.01 – Hospital identifiesindividual(s) responsible for theIC programEP 1 – Identifies individual(s)with clinical authority over theIC programEP 2 – When individual withauthority over IC programdoes not have expertise in IC,he or she consults withsomeone who has suchexpertise to make decisions
Crosswalk for Tag A-0748CMSA-0748Organization and Policies:A person(s) must bedesignated as infectioncontrol officer(s) to developand implement policiesgoverning control ofinfections/CD. Theinfection control officer(s)must develop a system foridentifying, reporting,investigating, andcontrolling infections/CD ofpatients and personnelTJC STANDARDSIC.01.01.01 – Hospital identifiesindividual(s) responsible for the ICprogram.EP 3 – Hospital assignsresponsibility for daily managementof IC activitiesEP 4 – Deemed status purposes:Individual with clinical authority isresponsible for:-Developing polices-Implementing policies-Developing system for identifyingreporting, investigating andcontrol infections/CD
Crosswalk for Tag A-0749CMSTJC STANDARDSA-0749Infection control officer(s) mustdevelop as system foridentifying, reporting,investigating, and controllinginfections/CD of patients andpersonnel.HR.01.04.01 – Hospital providesorientation to staffEP 4 – The hospital orientsstaff on the following:Specific job duties, includingthose related to infectioncontrol and assessing andmanaging painOrientation completion isdocumented
Crosswalk for Tag A-0749CMSTJC STANDARDSA-0749IC.01.01.01 – Hospital identifiesindividual(s) responsible for theIC programEP 4 – Deemed statuspurposes: Individual withclinical authority is responsiblefor:Developing policesImplementing policiesDeveloping system foridentifying, reporting,investigating and controlinfections/CDInfection control officer(s) mustdevelop as system foridentifying, reporting,investigating, and controllinginfections/CD of patients andpersonnel
Crosswalk for Tag A-0749CMSTJC STANDARDSA-0749IC.01.05.01 – The Hospital hasan IC PlanEP 8 – Hospital identifiesmethod for reporting infectionsurveillance and controlinformation to externalorganizationsInfection control officer(s) mustdevelop as system foridentifying, reporting,investigating, and controllinginfections/CD of patients andpersonnel
Crosswalk for Tag A-0749CMSA-0749Infection control officer(s) mustdevelop as system foridentifying, reporting,investigating, and controllinginfections/CD of patients andpersonnelTJC STANDARDSIC.02.01.01 – Hospitalimplements IC planEP 9 – Hospital reportsinfection surveillance,prevention, and controlinformation to local, state, andfederal public healthauthorities.
Crosswalk for Tag A-0756CMSA-0756Responsibilities of CEO,Medical Staff and Director ofNursing must:1) Ensure that the hospitalwide QAPI program andtraining programs addressproblems identified by theinfection control officer(s)2) Be responsible forimplementation andcorrective actionsTJC STANDARDSHR.01.05.03 – Staff participatein ongoing education andtrainingEP 1 – Staff participate inongoing education andtraining to maintain/increasecompetency. Staffparticipation is documented
Crosswalk for Tag A-0756CMSTJC STANDARDSA-0756IC.01.01.01 – Hospital identifiesindividual(s) responsible for theIC programEP 3 – The hospital assignsresponsibility for the dailymanagement of infectionprevention and controlactivitiesResponsibilities of CEO,Medical Staff and Director ofNursing must:1) Ensure that the hospitalwide QAPI program andtraining programsaddress problemsidentified by theinfection controlofficer(s)2) Be responsible forimplementation andcorrective actions
Crosswalk for Tag A-0756CMSTJC STANDARDSA-0756IC.01.05.01 – The hospital has aninfection prevention and control planResponsibilities of CEO,Medical Staff and Director ofNursing must:1) Ensure that the hospitalwide QAPI program andtraining programs addressproblems identified by theinfection control officer(s)2) Be responsible forimplementation andcorrective actionsEP 6 – All hospitalcomponents and functions areintegrated into the infectionprevention and controlactivities
Crosswalk for Tag A-0756CMSTJC STANDARDSA-0756Responsibilities of CEO,Medical Staff and Director ofNursing must:LD.01.02.01 – The hospital1) Ensure that the hospitalwide QAPI program andtraining programs addressproblems identified by theinfection control officer(s)2) Be responsible forimplementation andcorrective actionsidentifies the responsibilities of itsleadersEP 4 – Deem purposes: CEO,Medical Staff, and nurseexecutive make certain thatthe hospital-wide QAPI andtraining programs addressproblems identified by theindividual(s) responsible forinfection prevention andcontrol and that correctiveaction plans are successfullyimplemented
Other Important TJC StandardsIC.02.04.01 – Hospital offers vaccination against influenza toLIPs and Staff (9 EPs)1.2.3.4.5.6.Establish a programProvide educationMake vaccination convenientGoal for improving vaccination ratesSets incremental vaccination goals (achieve 90% by 2020)Written description of determining vaccination rates(NQF/NHSN def’n)7. Evaluates reasons given for declination8. Improves its vaccination rates9. Provides vaccination rates to key stakeholders annually
Other Important TJC StandardsNPSG.07.03.01 – Implement evidence based practices to prevent HAIsdue to MDROs (9 EPs)1.2.3.4.5.6.7.8.9.Periodic risk assessment for MDRO acquisition and transmissionEducation LIPs/Staff about HAIs, MDROs, and prevention strategiesannuallyEducate patients and families about MDROsSurveillance for MDROs based on risk assessmentMeasure and monitor MDRO prevention processes and outcomesProved MDRO outcomes and process data to key stakeholders (LIPs,leadership, staff)Implement polices and procedures based evidence-based MDROguidelinesImplement laboratory alert system that identifies new pts. withMDROsImplement alert system that identifies readmitted or transferredpatients positive for MDROs
Other Important TJC StandardsNPSG.07.04.01 – Implement evidence-based practices toprevent CLABSIs (13 EPs)1.2.3.4.5.6.7.8.9.10.11.12.13.Educate staff and LIPs involved in central lines annually (includeinvolvement into job descriptions)Education patients/families about CLABSIsImplement polices and procedures based on evidence-based guidelinesPeriodic risk assessments for CLABSI, compliance with practices, andevaluate prevention effortsProvide data (rates and outcome measures) to stakeholdersUse standardized insertion checklistPerform hand hygieneDo not use femoral vein (adults only), unless other sites unavailableUse standardized supply cart/kitUse standardized protocol for sterile barrier precautionsUse aseptic skin preparationUse standardized protocol to disinfect catheter hubs/ports beforeaccessingEvaluate all CVCs routinely and remove non-essential catheters
Other Important TJC StandardsNPSG.07.05.01 – Implement evidence-based practices to prevent SSIs(8 EPs)1. Educate all LIPs/Staff involved in surgical procedures2. Educate patients and families about SSI prevention3. Implement polices and procedures based on evidence-basedguidelines4. Conduct periodic risk assessments, select SSI measures basedon evidence-based guidelines, monitor compliance with bestpractices, and evaluate effectiveness of prevention efforts5. Measure SSI rates for first 30 days following procedure (1 yearfor implantables)6. Provide process and outcome measure results to stakeholders7. Administer antimicrobial prophylaxis according to methodcited in scientific literature or endorsed by professionalorganizations.8. When hair removal necessary, use method cited in scientificliterature or endorsed by professional organizations.
Other Important TJC StandardsNPSG.07.06.01 – Implement evidence-based practices to preventCAUTI (3 EPs)1. Insert indwelling urinary catheters according to establishedevidence-based guidelinesLimit use and duration to situations necessary for careUsing aseptic techniques2. Manage indwelling urinary catheters according to evidencebased guidelinesSecuring cathetersMaintaining sterility of collection systemReplacing collection system when requiredCollecting urine samples3. Measure and monitor CAUTI prevention processes andoutcomes
FederalInitiativesto reduceHAIs
Federal Initiatives to Reduce HAIsHHS HAI Action PlanPartnership for Patients (PfP)NHSNQIOsHENsCMS required reporting, VBP
HHS Action Plan Goals (2020)MeasureReduce central-line associatedbloodstream infections (CLABSI) in ICUand ward-located patientsDataSourceCDC/NHSNReduce catheter-associated urinary tract CDC/infections (CAUTI) in ICU and wardNHSNlocated sProposed Target for20202006-20081.0 SIR50% reduction or .50SIR46% reduction or .54SIR (2014)50% reduction from2015 baseline120091.0 SIR25% reduction or .75SIR6% increase or 1.06SIR (2014)25% reduction from2015 baseline2Reduce the incidence of invasivehealthcare-associated methicillinresistant Staphylococcus aureus (MRSA)infectionsCDC/EIP/ABC2007-200827.08 infections per100,000 persons50% reduction or 13.5infections per 100,000persons31% overall reductionor 18.6 infections per100,000 persons(2012)75% reduction from2007-2008 baseline3Reduce facility-onset methicillinresistant Staphylococcus aureus (MRSA)in facility-wide healthcareCDC/NHSN2010-20111.0 SIR25% reduction or .75SIR8% reduction or .92SIR (2013)50% reduction from2015 baselineReduce facility-onset Clostridium difficile CDC/infections in facility-wide healthcareNHSN2010-20111.0 SIR30% reduction or .70SIR10% reduction or .90SIR (2012)30% reduction from2015 baseline13.6 hospitalizationsper 1,000 discharges(2012 Projected)30% reduction from2015 baseline19% reduction or .81SIR (2012)30% reduction from2015 baselineReduce the rate of Clostridium difficilehospitalizationsAHRQ/HCUP2008Reduce Surgical Site Infection (SSI)admission and readmissionCDC/NHSN2006-200811.6 hospitalizations with 30% reductionC. difficile per 1,000discharges1.0 SIR25% reduction or .75SIR
Partnerships for PatientsHospital Engagement Networks26 National, Regional, Stateand Hospital System levelHENsCAUTICLABSISSIVAP/VAEHospital Improvement andInnovation Networks (HIINS)The period of performance forthe HIINs begins in September2016 through 2019 and consistsof one 24-month base periodand one 12-month option year,to implement and spread welltested, evidence-based bestpractices.-12% reduction in 30 dayreadmission-20% decrease in overall harm
thQIO Activity in 11 SOW: HAIsQIOs will work to reduce the following HAIs in hospitals(ICU and non-ICU wards) the 11th SOW:Central line bloodstream infections (CLABSI)Catheter-associated urinary tract infections (CAUTI)Clostridium difficile infections (CDI)Surgical site infections (SSI)
Thank You!
CMS and Joint Commission Karen K Hoffmann RN MS CIC FSHEA FAPIC. Disclaimer . Section 4.A. - Urinary Catheter Tracer Section 4.B. - Central Venous Catheter Tracer Section 4.C. - Ventilator/Respiratory Therapy Tracer . tool Final version will change to accommodate surveyor needs. CMS - Joint Commission Crosswalk.
