Interim deadlines keep you on track to compliance
"Milestones" must be met for new infection control
The newest requirement for compliance with Goal 7 of the 2009 Joint Commission National Patient Safety Goals is "Implement best practices or evidence-based guidelines to prevent central line-associated bloodstream infections." The requirement applies to short- and long-term central venous catheters and peripherally inserted central catheter lines. The requirement has a one-year phase-in period that includes specific milestones with defined expectations for planning, development, and testing. Full implementation of a process that meets the requirements of the patient safety goal is expected no later than January 1, 2010.
Deadlines throughout the year are: April 1, 2009: The organization's leadership has assigned responsibility for oversight and coordination of the development, testing, and implementation of the goal to reduce healthcare-associated infections related to central lines. July 1, 2009: An implementation work plan is in place that identifies adequate resources, assigned accountabilities, and a timeline for full implementation by January 1, 2010. October 1, 2009: Pilot testing is under way for the requirements. January 1, 2010:
- The elements of performance are fully implemented across the organization.
- The organization educates health care workers who are involved in these procedures about health care associated infections, central line-associated bloodstream infections, and the importance of prevention. Education occurs upon hire, annually thereafter, and when involvement in these procedures is added to an individual's job responsibilities.
- Prior to insertion of a central venous catheter, the organization educates patients, and their families as needed about central line-associated bloodstream infection prevention.
- The organization implements policies and practices aimed at reducing the risk of central line-associated bloodstream infections that meet regulatory requirements and are aligned with evidence-based standards.
- The organization conducts periodic risk assessments for surgical site infections, measures central line-associated bloodstream infection rates, monitors compliance with best practices or evidence-based guidelines, and evaluates the effectiveness of prevention efforts.
- The organization provides central line-associated bloodstream infections rate data and prevention outcome measures to key stakeholders including leaders, licensed independent practitioners, nursing staff, and other clinicians.
- Use a catheter checklist and a standardized protocol for central venous catheter insertion.
- Perform hand hygiene prior to catheter insertion.
- Use a standardized supply cart or kit that is all-inclusive for the insertion of central venous catheters.
- Use a standardized protocol for maximum sterile barrier precautions during central venous catheter insertion.
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