“the stony brook way is my way” new york state department of health center for medicaid medicare...
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“The Stony Brook Way is My Way”
New York State Department of HealthCenter for Medicaid Medicare Services
[CMS]
All Cause Corrective ActionStony Brook Medicine
DOH References 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 implemented prior to DOH exit (policy #RI 0057) 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
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”
Infection Control is in Your Hands
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: On hand hygiene practices and Patients isolation
HEALTHCARE EPIDEMIOLOGY DEPARTMENT
Infection Control is in Your Hands
All patients, regardless of status:• inpatient• outpatient• observation
Must be placed on the correct isolation precautions based upon:
• personal history• clinical presentation• isolation code on Banner Bar
HEALTHCARE EPIDEMIOLOGY DEPARTMENT
DISEASE - SPECIFIC PRECAUTIONS
Visit or s VISITANTES: FAVOR DE ANUNCIARSE A LA ENFERMERA DE PISO ANTES DE ENTRAR AL CUARTO REPORT TO NURSES’ STATION BEFORE ENTERING ROOM
MASKS □ No □ Yes Fitted N95 Respirator □ No □ Yes
GOWNS □ No □ Yes
GLOVES □ No □ Yes
GOGGLES / FACE SHIELD
□ No □ Yes
□ For all those close to patient □ If soiling is likely □ For touching infective material □ For all those close to patient
□ For all persons entering room
□ For all persons entering room
□ For all persons entering room □ For all persons entering room
Wash hands with soap and water only. □ No □ Yes
Hands must be washed before donning and after removing gloves, touching the patient or patient’s environment, and before taking care of another patient.
Private room indicated? □ No □ Yes
HA2N002 (4/18/11)
NURSE
INFECTION CONTROL PRACTITIONER
Isolation Card (front)
HEALTHCARE EPIDEMIOLOGY DEPARTMENT
Infection Control is in Your Hands
Infection Control is in Your Hands
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
Infection Control is in Your Hands
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
Infection Control is in Your Hands
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
HEALTHCARE EPIDEMIOLOGY DEPARTMENT
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
ALL CAUSE CORRECTIVE ACTIONS
“The Stony Brook Way is My Way”
Please sign and date the attestation faxed to you
EMAIL to: [email protected]
Type your name - LAST NAME, FIRST NAME in the SUBJECT of email
If you are unable to email, please fax to:
631-706-3329