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“The Stony Brook Way is My Way”
Stony Brook Medicine: Response to Quality Assurance and Performance Improvement
What We Need to Know
New York State Department of HealthCenter for Medicaid Medicare Services
[CMS]
All Cause Corrective ActionStony Brook Medicine
Developed 6/10/2015 Reviewed 6/19/2015 cm
DOH/CMS Areas of Deficiency:
1. Allegations of Sexual, Physical, or Psychological Abuse
2. Infection Control Practices3. Intravenous Therapy and Blood Product
Administration4. HIPAA, as it relates to PHI Disclosure5. Code Cart Standardization
“The Stony Brook Way is My Way”
1. Didactic education
2. Skills based training and Simulation
3. Attestation- confirmed completion
4. Validation- check performance
5. Outcomes- compliance
IMPLEMENTATION /COMMUNICATION STRATEGY
“The Stony Brook Way is My Way”
• DOH for CMS Allegation survey 4/28/15 – 5/4/15
• Finding related to process for investigation of patient complaints of Abuse & Neglect by a Staff member
• Actions: New Policy RI0057: Patient Allegations of Abuse/Neglect by a Staff
Member implemented prior to DOH exit Education to front line, managers, supervisors, directors & medical
staff via PPs, LMS, and continuing through annual re-certifications and new employee orientation
Abuse Complaint checklist to document actions
Policy: RI:0057 https://policymanager.uhmc.sunysb.edu/dotNet/documents/?docid=6063&mode=view
CMS ALLEGATION SURVEY
“The Stony Brook Way is My Way”
• CMS document received evening of 6/3/2015 (on day 3 of TJC Survey)
• Follow up actions and clarification statements to be submitted by 6/15/2015
• Requires 100% education : Medical Staff must complete to 100% by 6/15/2015
• Requires 100% monitoring of responses to Abuse & Neglect complaints (13 to date since DOH visit)
• Requires feedback to Departments on Abuse & Neglect complaints
• Requires tracking & trending by department and individual
CMS REPORT 5/13/2015
“The Stony Brook Way is My Way”
“The Stony Brook Way is My Way”
Administrative Policy on Isolation Precautions IC 0006
As soon as patients are identified as needing isolation:• Yellow card / chart, dedicated stethoscope / thermometer
• All rooms must have a Personal Protection Equipment [PPE] cabinet
in or in close proximity to the entryway• Cabinets must be stocked with gowns, gloves, surgical masks,
goggles and / or face shields• All HCWs are responsible for following the isolation precautions
delineated in the Hospital Policy and reminding other HCWs to do the same
• Families must be educated re: Hand hygiene practices and Patient’s isolation
HEALTHCARE EPIDEMIOLOGY DEPARTMENT
“The Stony Brook Way is My Way”
All patients, regardless of status:• inpatient• outpatient• observation
Must be placed on the correct isolation precautions based upon the patient’s:
• personal history• clinical presentation• isolation code on Banner Bar
HEALTHCARE EPIDEMIOLOGY DEPARTMENT
“The Stony Brook Way is My Way”
Administrative Policy on Hand Hygiene IC 0003
Hand Hygiene is performed:• Upon entering & exiting patient rooms• Before and after any contact with patient / environment,
regardless of +/- isolation status• In between dirty and clean procedures• Between separate portions of the physical exam re: clean vs dirty• OK to foam when entering a C diff room, but must wash hands
with SOAP / WATER upon exiting
Families must be educated on hand hygiene practices
DEPHEALTHCARE EPIDEMIOLOGY DEPARTMENT
ORMATICS
“The Stony Brook Way is My Way”
Administrative Policy on Infection Control in patient transporting IC 0007
Patients on isolation must be transported using practices that minimize cross contamination
If patient is on isolation, the transporter must:• Perform hand hygiene, don correct PPE identified on the isolation yellow card before
entering room• Bring clean transfer equipment into the room, transfer patient to stretcher or wheelchair
as indicated• Cover patient with clean sheet• Remove isolation garb before exiting room, perform hand hygiene• When transferring patient on occupied bed, wipe the side rails and all accompanying
equipment with antimicrobial (purple) wipes, allowing for 2 minute dwell time prior to exiting the room
HEALTHCARE EPIDEMIOLOGY DEPARTMENT
“The Stony Brook Way is My Way”
Administrative Policy on Infection Control in Patient Transporting IC 0007
• Patients on droplet and airborne precautions must themselves wear a well fitted surgical mask during transport prior to leaving the room to contain their secretions, thus preventing dissemination
• All other patients do not require a mask as the
mode/mechanism of transmission is not via droplet secretion
“The Stony Brook Way is My Way”
Health Care Providers are NOT to carry multi-dose vials in pockets or case (pharmacy policy modified):
• From patient to patient• From room to room• When used on a patient with an infection, discard after use
Use single-dose containers whenever possible
When single-dose dispensers are not available:• Maintain aseptic technique• Perform hand hygiene• Prevent tip of dispenser from touching the patient• Wipe down container with antimicrobial (purple) wipes in between
every patient encounter and prior to returning it to the case.
HEALTHCARE EPIDEMIOLOGY DEPARTMENT
SBU Hospital Infection Control Policies • Hand Hygiene IC 0003• Multidrug Resistant Organisms (M-RO) IC 0010• Patient Care Equipment Cleaning IC 0013• Infection Control In Patient Transporting IC 0007• Isolation Precautions IC 0006• Prevention and Control of Clostridium defficile IC 0022• Prevention and Transmission of M. Tuberculosis
infection IC 0011• MM0012 Multiple Dose Vials, Multiple Use Containers• IC0012 Standard Precautions
Infection Control is in Your Hands
All consultants [MDs, NPs, PAs, etc] will notify primary nurse of their arrival prior to
entering patient room in ED and on the Units: “I’m here to see patient ____. Is there
anything I should know?”
“The Stony Brook Way is My Way”
Audit and analysis of all IV and Blood Administration Policies
Development of educational materials aligned with best practices and SBUH policies
• Development of Skills Training stations• Development of Simulation scenarios• Training of Auditors• Systematic ongoing monitoring
IV THERAPY AND BLOOD ADMINISTRATION
“The Stony Brook Way is My Way”
Removed complete patient name from slave monitors
• Rolling computer carts: instructing and auditing for open EMRs with PHI on the screen
• Education on the proper communication of PHI, with instruction for sensitivity to the environment and other people: only permitted use of incidental disclosure
HIPAA COMPLIANCE: PROTECTED HEALTHCARE INFORMATION
“The Stony Brook Way is My Way”
All Pediatric and Adult Code Carts now include the appropriate Zoll Pads
Pediatric Code Cart now contains two sets of Zoll Pads: Children less than 8 years of age and over 8 years of age
All Code Carts now have consistent Code Cart checklists
CODE CART STANDARDIZATION
“The Stony Brook Way is My Way”
Accountability• Attestation of all staff by 6/15/2015• Validation of training and education 6/15-6/20/2015• Remediation directives-as it occurs• Behavior-Based Expectations- continuous• Ongoing monitoring of outcomes• Patient Safety Rounding will include CMS Hospital Infection Control
Worksheet with relevant scoring.
ALL CAUSE CORRECTIVE ACTIONS
“The Stony Brook Way is My Way”