Infection control is focus for 2011
AAAHC announced changes
Accreditation organizations are making an "all-out effort" to focus on safe needle use in 2011, according to Marsha Wallander, RN, assistant director of accreditation services at the Accreditation Association for Ambulatory Health Care (AAAHC).
AAAHC and The Joint Commission are participating in the Safe Injection Practices Coalition and its One and Only Campaign (www.oneandonlycampaign.org) to promote one needle, one syringe, only one time. "We're all jumping on the same thing," Wallander says. (For more on The Joint Commission's focus, see "On-site Survey: Focus on Safe Injection Practices," Same-Day Surgery Weekly Alert, July 23, 2010. To subscribe to this free weekly ezine, contact customer service at [email protected] or (800) 688-2421.)
The emphasis on needles is part of a broader focus on infection control and prevention, Wallander says. That focus includes cleaning and high level disinfection of surgical instruments including endoscopy scopes. Use practices that ensure those instruments are sterile, she emphasizes. "That's our thrust for 2011," she says.
Another addition for next year is that a facility must be able to show documented evidence of period testing and preventive maintenance, according to manufacturers recommended guidelines for critical pieces of equipment, Wallander says. "There's been some lapses in the health care environment," she says.
One of the most frequently asked questions
Another changes for 2011 is acknowledgement that electronic records are becoming prominent in ambulatory settings, Wallander says. Facilities frequently ask about what to do if they are in transition to electronic records, she says.
"It's perfectly fine for an organization to be in a transitory state when we come in to survey," Wallander says. "We understand that it's part of doing business and we expect that the organization has done an implementation plan that keeps its records organized and available for providers who need access."
Another issue that has popped up for accredited organizations is that sometimes the patients are not clear about which specific parts of an organization have been accredited, she says. Consider the example of a large multi-specialty clinic that also has an ambulatory surgery center attached to it. The ASC might be accredited, but the primary care clinical side might not be.
"Organizations will need to be clear about how they represent accreditation," Wallander says. "They need to make sure the patient population is advised what is and what is not accredited."
Another area that AAAHC has clarified is that managers performing quality improvement (QI) studies seemed to think those studied needed to be limited to a problem, issue, or adverse event, she says. "We clarified that QI can look not just at problems, but processes that organization may feel need to be looked at," Wallander says. "They are given credit for those QI programs that aren't simply problem-related, but a process improvement related."
The new standards will be available at the beginning of January, and compliance is expected by July, Wallander says.
The Joint Commission revises NPSGs While The Joint Commission will have no new National Patient Safety Goals (NPSGs) for 2011, it has revised elements of performance (EPs) within those goals to remove specific requirements related to clinical practice.1 The changes to the EPs are effective immediately. Those changes include the EPs for NPSG 07.05.01, implement evidence-based practice for preventing surgical site infection. The EP is applicable to ambulatory care, hospitals, critical access hospitals, and office-based surgery practices. The NPSG requires accredited organizations to administer antimicrobial agents for prophylaxis for a particular procedure or disease according to methods cited in scientific literature or endorsed by professional organizations (no longer "evidence-based best practices"). The Joint Commission will not accept practices that are not supported by evidence or widespread consensus. "During the on-site survey, surveyors will explore the source of the practices the organization follows," it says. The following EPs have been removed:
The NPSG also says that when hair removal is necessary, use a method that is cited in scientific literature or endorsed by professional organizations ("Clippers or depilatories" has been removed). The Joint Commission says that a limited number of NPSGs contain requirements for practices that reflect current science and medical knowledge. "In these cases, the element of performance refers to a practice that is cited in scientific literature or endorsed by professional organizations," it says. "This means that the practice used by the organization must be validated by an authoritative source. The authoritative source may be a study published in a peer-reviewed journal that clearly demonstrates the efficacy of that practice or endorsement of the practice by a professional organization(s) and/or a government agency(ies)." [For information on changes to the medication reconciliation NPSG, see "Joint Commission to Revise NPSG on Medication Reconciliation Again," Same-Day Surgery Weekly Alert, Aug. 13, 2010.] Reference
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