Helen Bucknell FAAQHC CICP Cert IV TAE RN BN Quality and Infection Control Consultant
Session Outline Draft Revised Standard 3 criteria (not yet endorsed) • Main changes or focus areas • Content of draft action items • Links to other draft standards • Summary
ADVERSE OUTCOMES RELATED TO Healthcare Acquired Infections
NSQHSS 3 snapshot Current version NS 3 has 41 action items Draft revision has 16 action items BUT (some have many subsets) The new version remains: • Broad, Multidisciplinary • Multifactorial • Will require data analysis, monitoring, reporting structures • Must show evidence of continuous improvement for patient and staff safety
1. Governance and systems for 1. Clinical governance & quality improvement to prevent and infection prevention, control and surveillance control HAI, and support antimicrobial stewardship 2. Infection prevention and control strategies 2. Infection prevention and control 3. Managing patients with systems infections or colonisations 3. Reprocessing of reusable 4. Antimicrobial stewardship medical devices 5. Cleaning, disinfection and 4. Antimicrobial stewardship sterilization 6. Communicating with patients and carers 6 overarching criteria 4 overarching criteria
MAIN CHANGES • Increased focus on risk management • AMS (now includes the requirement to meet the Clinical Care Standard) • Reprocessing of Reusable Medical Devices – now stand alone criteria. • Language and definitions changed slightly to make meanings clearer.
Intent of standard 3 (version 1 NSQHSS): Prevent patients from acquiring preventable HAI and effectively manage infections when they occur by using evidence-based strategies. Intent of draft standard 3 (version 2 NSQHSS): Reduce the risk of patients acquiring preventable HAI, effectively manage infections if they occur, and limit the development of antimicrobial resistance through prudent use of antimicrobials as part of antimicrobial stewardship.
NSQHSS 1 Clinical Governance NSQHSS 3 Other Responsibilities : Infection Prevention & Quality, Clinical, FEEDBACK Control Maintenance etc STAFF & PATIENT SAFETY OPERATIONAL Service Delivery: Nursing and other Staff, Clinicians, Maintenance, Environmental Services, Medication, Catering etc Patient Outcomes & engagement
Clinical Governance & Quality Improvement Version 2 (draft) 3.1 Integrating clinical governance Workforce uses safety and quality systems from the clinical governance of the organisation for: Policies and procedures, managing risk, training and antimicrobial stewardship (AMS). Link to V1 (3.1.1, 3.1.2, 3.3.1, 3.5.2, 3.7.1, 3.9.1, 3.15.2, 3.18.1) 3.2 Applying quality improvement systems Organisation applies the quality improvement system in the Clinical Governance Standard when: Monitoring systems for preventing and controlling HAI. Implementing strategies to improve outcomes of IC systems. Reporting and taking action on outcomes of HAI. Link to V1 (3.1.2,3.1.3, 3.1.4, 3.3.2, 3.4.1, 3.4.2, 3.4.3.3.10.3.3.112, 3.11.3.3.11.4, 3.11.5, 3.14.3)
Clinical Governance & Quality Improvement Version 2 (draft) 3.3 Partnering With Consumers Linking with Standard 2 to: • Actively involve consumers in their care • Meet patient information needs • Share decision making Link to V1 (3.19.1, 3.19.2) 3.4 Surveillance Surveillance strategies that include: • Data collection • Monitoring and use of surveillance data to reduce risks • Reporting data to the workforce, governing body and consumers Link to V1 (3.2.1, 3,2,2)
Infection Prevention & control Systems Version 2 (draft) 3.5 Standard and transmission based precautions consistent with state and national guidelines / IC requirements 3.6 Assess risks and use transmission based precautions (7 criteria) 3.7 Communicating infectious status when transferring care Link to V1 (3.7.1, 3.11.1, 3.12.1, 3.13.1, 3.13.2)
Infection Prevention & control Systems Version 2 3.8 Hand Hygiene Program consistent with national and jurisdictional requirements. Address non compliance. Link to V1 (3.5.1, 3.5.3) 3.9 Aseptic Technique Identifying where AT applies, staff training, addressing gaps in competency. Monitoring compliance. Link to V1 (3.10.1, 3.10.2)
Infection Prevention & control Systems Version 2 (draft) 3.10 Invasive Medical Devices Use and management of invasive devices in accordance with national IC guidelines. Link to V1 (3.8.1)
Infection Prevention & control Systems Version 2 (draft) 3.11 Maintaining clean and hygienic environment: Responding to risks, training staff • 3.12 Processes to evaluate and respond to infection risks for : New and existing equipment, devices and • products Maintaining, and upgrading buildings, • equipment, furnishings and fittings Handling, transporting and storing linen • Link to V1 (3.15.1, 3.15.3 and NEW COMPONENTS 3.12 )
Infection Prevention & control Systems Version 2 (draft) 3.13 Risk based immunisation program that is: • Consistent with national guidelines and jurisdictional requirements • Addresses specific risks to the workforce and patients Link to V1 (3.6.1)
Reprocessing of reusable medical devices Version 2 (draft) 3.14 Processes for Reusable equipment, instruments and devices consistent with relevant national and international standards and manufacturer's guidelines – 5 year implementation plan. Traceability process to identify: • Patient • Procedure • Reusable equipment, instruments and devices Link to V1 (3.16.1, 3.17.1 )
Antimicrobial stewardship 3.15 Antimicrobial Stewardship program; includes: • Policy • Promotion of therapeutic guidelines • Approved formulary • Inclusion of Clinical Care standard for AMS 3.16 The program will : • Review prescribing and use • Use surveillance data to support prescribing • Report outcomes to clinicians and governing committee; implement improvements Link to V 1 (3.14.1, 3.14.2, 3.14.3, 3.14.4)
Antimicrobial Stewardship Clinical Care Standard 3.15 d
REVISED DRAFT STANDARD 3 AND LINKS WITH OTHER STANDARDS STANDARD 1 STANDARD 2 CLINICAL PARTNERING GOVERNANCE FOR WITH HEALTH SERVICE CONSUMERS ORGANISATIONS STANDARD 8 ACUTE STANDARD 4 DETERIORATION STANDARD 3 MEDICATION PREVENTING AND SAFETY CONTROLLING HAI Governance STANDARD 7 Policies Tools STANDARD 5 BLOOD Audits Training COMPREHENSIVE MANAGEMENT Quality CARE Improvement STANDARD 6 COMMUNICATING FOR SAFETY
Summary • New draft standard 3 - will remain broad, multi- disciplinary and require significant evidence • Defined and documented Clinical Governance framework • Continue progression of 5 year AS/NZS 4187: 2014 plan • Although there are 16 overarching action items there are 36 actions in total counting subsets!
References • Exploring Context for effective clinical governance in infection control (2016) Halton Kate, Hall Lisa, Gardner Ann Macbeth Deborough, Mitchell Brett AJIC (Dec 2 2016) • Australian Commission on Safety and Quality in Health Care (2016) National safety and Quality Health Service Standards Version 2 . Sydney, Australia: Australian Commission on Safety and Quality in Health Care • National Health and Medical Research Council (2010) Australian guidelines for the prevention and control of infection in healthcare . Canberra, Australia: Commonwealth of Australia
Attachment 1 IC Governance Standing agenda Items (the Minimum) Review policies and procedures - facility specific Monitor Compliance & HAI Surveillance data Environmental surveillance and compliance Review of IC incidents and complaints Reporting and risk identification (review of IC risks on risk register) Endorsement of audit tools and surveys , Training Needs Analysis and monitoring training compliance Monitoring compliance rates with HCW immunisation programs Quality activities / Continuous Improvement to reduce HAI Managing up and reporting accurately on achievements and shortfalls/risks in the program Reports on other items e.g antimicrobial stewardship, reprocessing RMDs, clinical product review
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