Executive Summary

Topics: Hospital, Infectious disease, Patient Pages: 7 (1454 words) Published: March 3, 2014

Executive Summary - Infection Control and Prevention Current Compliance Status for Joint Commission Accreditation Nightingale Community Hospital is committed to providing healthcare excellence, a healing environment and to be the choice for patient care. In order to continue to provide quality healthcare services in accordance with our values of safety, community, teamwork, and accountability Joint Commission Accreditation provides guidelines and standards for the Priority Focus Areas (PFA) for the welfare and quality of patient care. Infection control and prevention extends beyond treating the patient. It encompasses all who work and visit the facility including medical staff, administrative staff, volunteers, vendors, and visitors. Implementing activities and programs to control, treat, prevent and identify sources of infection will help ensure the overall satisfaction and quality of patient care. Based on previous fiscal year data Joint Commission has identified Infection Control as one of the PFAs. In order to be in compliance with the standards and guidelines of Joint Commission Accreditation five areas of Infection Control and Prevention have been identified: 1. The hospital implements its infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection. 2. Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. 3. Implement evidence-based practices to prevent healthcare– associated infections due to multidrug-resistant organisms in acute care hospitals. 4. Implement evidence-based practices to prevent central line– associated bloodstream infections. 5. Implement evidence-based practices for preventing surgical site infections. There are opportunities to implement and to improve on established programs for Infection Control and Prevention. Establishing and reinforcing Nightingale Community Hospital’s commitment to implement programs and improve on identifying, preventing and controlling infections will reduce cost of care while improving patient safety and education. Multidrug Resistant Organisms

Current Compliance Status
Patients continue to be at risk for nosocomial transmissions that are multidrug- resistant. Nosocomial transmissions did not meet the Joint Commission Accreditation standards 7 out of the 12 months.

Number of MDRO Infections
Rate/1000 Patient Days
January
0
0
February
4
1.5
March
2
0.75
April
2
0.5
May
1
0.25
June
1
0.25
July
0
0
August
1
0.25
September
1
0.25
October
0
0
November
0
0
December
0
0

Although there was a reduction rate of Mulitdrug-resistant organisms (MDROs) from February through August, the 12-month rolling rate average is 3.2 infections/1000 patient days. The current goal set by Nightingale Community Hospital is < 0.15 infections/1000 patient days. Joint Commission Accreditation Standard

Reduce the risk of health care-associated infections (2013 The Joint Commission). There are nine Elements of Performance (EPs) that are required and that have direct impact on patient care: 1. Conduct periodic risk assessments (in time frames defined by the hospital) for multidrug-resistant organism acquisition and transmission. 2. Based on the results of the risk assessment, educate staff and licensed independent practitioner about HAIs, MDROs, and prevention strategies at hire and annually thereafter. 3. Educate patients, and their families as needed, who are infected or colonized with a MDRO about healthcare–associated infection prevention strategies. 4. Implement a surveillance program for MDRO based on the risk assessment. 5. Measure and monitor multidrug-resistant organism prevention processes and outcomes. 6. Provide MDRO process and outcome data to key stakeholders, including leaders, licensed independent practitioners, nursing staff, and other...
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