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February 2016 Archive for High Reliability Healthcare

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Systemic solutions to analyze underlying causes of specific care breakdowns and improve overall quality.

Addressing the No. 1 issue

Feb 12, 2016 | Comments (0) | 10505 Views

By Ana Pujols McKee, MD.

 Executive Vice President and Chief Medical Officer

When something is ranked No. 1, it’s best to take notice. When it’s the No. 1 cause of immediate threat to life and preliminary denial of accreditation, it’s even better to take action. So we did.

In looking at our data, we’ve noticed a disturbing trend. Hospitals, ambulatory health care settings, ambulatory surgery centers and office-based surgery centers accredited by The Joint Commission continue to uncover serious noncompliance issues with the Infection Prevention and Control Standard IC.02.02.01 EP 2. This standard addresses minimizing the risk of transmission of infection with medical equipment, devices and supplies.

Through the first half of 2015, 54 percent of hospital surveys uncovered serious noncompliance issues with standard IC.02.02.01 EP 2, which was higher than all of 2014. The numbers were actually worse for the other three settings when compared to all of 2014.

  • Critical access hospital — 60 percent noncompliance (9 percent increase from 2014)
  •  Ambulatory surgery centers — 46 percent (5 percent increase from 2014)
  • Office-based surgery practices — 53 percent (14 percent increase from 2014)

We knew something needed to be done to try and combat the problem, and with that in mind, we recently released a High-Level Disinfection (HLD) and Sterilization BoosterPak. A Standards BoosterPak is a searchable document for accredited organizations intended to provide detailed information about a single standard or topic area that has been associated with a high volume of inquiries or non-compliance scores in the health care field.

The goal for this particular BoosterPak is simple: to ensure practices are carried out following regulatory standards and evidence-based guidelines for HLD and sterilization in order to minimize the potential risk of infection transmission to patients.

How does it do this? By using information and methods to address the problem. In this case, the information is targeted toward frontline staff conducting HLD and sterilization processes, those that supervise HLD and sterilization, and infection preventionists. However, the content is modular and is broken down into such categories as leadership, risk assessment, sterilization and others.

The leadership module is of particular importance in my opinion. An organization’s leadership needs to provide careful oversight of these areas and the appropriate resources for training and competency evaluation. They cannot simply assume staff are knowledgeable of these procedures, but instead must base their judgments on objective competency assessments conducted annually or more frequently as necessary.

That’s where the BoosterPak comes in. It offers resources and tools for leadership to do such assessments, which in turn will help the front-line staff. Hopefully these resources will help find the No. 1 solution to the No. 1 problem.