Health Center

Infection Control
Lorrie Cappellino, RN, MS
Ambulatory Surveyor, The Joint Commission

July 19, 2019

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 Health Center
Infection Control (IC)
Purpose
Background Information
IC Risk Assessment
IC Plan
Targeted health center IC tool
Q&A

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Purpose of Today’s Presentation
Make good on our commitments to you
– Be a collegial/collaborative partner
– Be transparent
– Help identify risks
– Be educational
Additionally
– Help enhance quality/safe patient care
– Help identify/reduce process problems

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– Help improve organizational success
– Inspire your organization to improve/excel
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 The Joint Commission’s Mission

To continuously improve health care for the public,

in collaboration with other stakeholders, by
evaluating health care organizations and

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inspiring them to excel in providing safe and
effective care of the highest quality and value.

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 The Joint Commission’s Vision

All people always experience the safest, highest

quality, best-value health care across

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all settings.

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 Our Organizing Principle

Leading the Way to Zero

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 Imagine a Day of Zero

Zero complications of care

Zero missed opportunities
Zero overuse
Zero harm
Zero lost revenue
Zero harm events of any kind

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 © Copyright, The Joint Commission
Information relates to health center TJC reports dated 2/13/2017 – 9/5/2018; multiple IC topics
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may have been referenced under each finding; excludes APR findings
 Organization’s IC Program
IC Risk Assessment + IC Plan = foundation
of the IC Program
Risk Assessment is the starting point
Use the risk assessment to identify important
issues for your organization
Create IC Plan that includes goals for your
health center
IC Program should be meaningful and

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individualized for your health center

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 IC Risk Assessment

Identifies risks for transmitting

infections
Assists in focusing surveillance and
other regulatory activities
Risks are identified annually and when
changes occur

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 IC Risk Assessment
Factors to Include

Geographic location
Environment concerns
Population served
Area endemic concerns
Care, treatment and services provided

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Regulatory/state specific requirements

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 Assign Values Based on Risk
Probability of event occurring
– Known risk, historical info, research data
Impact/severity
– Threat to life, service impact, financial loss
Current system
– Training status, policies, back-up systems

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Rank order risk

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 Assign Values Based on Risk

Score each item

Rank order using risk scale
Each organization’s priorities will be
different

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 APIC
Sample Risk
Assessment Tool
and
Examples for Health
Centers

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Infection Control Risk Assessment, APIC
APIC Infection Control Risk Assessment Tool
(Fillable)

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Infection Control Risk Assessment, APIC
APIC Infection Control Risk Assessment
Tool Health Center Examples

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Infection Control Risk Assessment, APIC
APIC Infection Control Risk Assessment
Tool Health Center Examples

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Infection Control Risk Assessment, APIC
 Sample IC Prioritized Risks
Health Center Examples
Risk #1: Hand Hygiene Compliance
(scored a 7 on the risk assessment)
Risk #2: Instrument Decontamination
Processing Compliance
(scored a 7 on the risk assessment)
Risk #3: Flu Vaccine Compliance

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(scored a 6 on the risk assessment)
Risk #4: Dental Site Infection Rate
(scored a 5 on the risk assessment)
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 Infection Control Plan

Based on prioritized risks (from risk

assessment)
Includes measurable goals
Includes strategies for implementation
Plan is written and evaluated annually

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 Infection Control Plan
Rank order priorities
Use top risks/highest priorities to set
goals (3/4/5?)
Goals are broad statements
Develop measurable objective for each
goal
Design steps (strategy) to meet goal

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Determine how you will measure
success (meet goal)
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Risk Assessment and Plan Done
with Interdisciplinary Input
Medical providers
Dental providers
Administrators
Nursing
Staff from sterilization/HLD department
Leaders

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Employee health
Others
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 Sample IC Prioritized Risks
Health Center Examples
Risk #1: Hand Hygiene Compliance
Risk #2: Instrument Decontamination
Processing Compliance
Risk #3: Flu Vaccine Compliance
Risk #4: Dental Site Infection Rate

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Health Center IC Goals Examples
Time Frame, Make Measurable
Goal Risk #1: To improve hand hygiene
guideline compliance rate to 75%
Goal Risk #2: To improve instrument
decontamination processing
compliance to 98%
Goal Risk #3: To increase annual flu

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vaccine compliance rate to 90%
Goal Risk #4: To reduce dental site
infection rate to 0.01%
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 Health Center
Infection Control
Tool/Checklist

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Infection Control References
 2008 CDC Guideline for Disinfection and Sterilization in Healthcare Facilities.”
Centers for Disease Control and Prevention

 2018 Association of Perioperative Registered Nurses, AORN Guidelines for

Perioperative Practice
 American Dental Association (ADA) Policy Statement on Infection Control in the
Practice of Dentistry - https://www.ada.org/en/member-center/oral-health-
topics/infection-control-resources

 ANSI/AAMI ST58, Chemical sterilization and high-level disinfection in health care

facilities
https://my.aami.org/aamiresources/previewfiles/ST58_1308_preview.pdf

 ANSI/AAMI ST79, Comprehensive guide to steam sterilization and sterility

assurance in health care facilities

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https://my.aami.org/aamiresources/previewfiles/1709_ST79Preview.pdf

 ANSI/AAMI ST91, Flexible and semi-rigid endoscope processing in healthcare

https://www.aami.org/productspublications/ProductDetail.aspx?ItemNumber=247
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Infection Control References
 APIC Infection Control Risk Assessment Template
https://www.google.com/search?q=apic+infection+control+risk+assessment&rlz
=1C1GCEU_enUS826US826&oq=APIC+Infection+Control+Risk+Assessment&aq
s=chrome.0.0l2.11136j0j9&sourceid=chrome&ie=UTF-8

 APIC Infection Control Risk Assessment Example

https://apic.org/Resource_/TinyMceFileManager/Academy/ASC_101_resources
/Risk_Assessment/Risk_Assessment_Example_2.docx

 APIC Text of Infection Control and Epidemiology. 4th Edition. 2014

 CDC Guide to Infection Prevention for Outpatient Settings: Minimum Expectations

for Safe Care (Both the guide and checklist).
https://www.cdc.gov/hai/settings/outpatient/outpatient-care-guidelines.html

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 “Cleaning, Disinfection and Sterilization,” APIC Text on Infection Control and
Epidemiology http://text.apic.org.eu1.proxy.openathens.net/toc/basic-principles-
of-infection-prevention-practice/cleaning-disinfection-and-sterilization

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Infection Control References

 IAHCSMM educational materials: www.iahcsmm.org/education/online-lessons.html

 “Infection Prevention Checklist for Dental Settings Basic Expectations for Safe Care,”
https://www.cdc.gov/oralhealth/infectioncontrol/pdf/safe-care-checklist.pdf

 Recommendations from the Guidelines for Infection Control in Dental Healthcare

Settings – 2003.
https://www.cdc.gov/oralhealth/infectioncontrol/pdf/recommendations-
excerpt.pdf

 The Joint Commission High Level Disinfection and Sterilization Booster Pack:
https://www.jointcommission.org/assets/1/6/TJC_HLD_BoosterPak.pdf

 “Using the Risk Assessment to Set Goals and Develop the Infection Prevention and

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Control Plan.” Joint Commission Resources
https://www.jcrinc.com/using-the-risk-assessment-to-set-goals-and-develop-the-
infection-prevention-and-control-plan/

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 Health Center
Infection Control (IC)
Purpose
Background Information
IC Risk Assessment
IC Plan
Targeted health center IC tool

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Q&A

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 Questions?

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