October 20, 2009
Kelly L. Podgorny, RN, MS, CPHQ
© Copyright, The Joint Commission
The Joint Commission’s
HAI-Focused NPSG
I.
The Joint Commission: Culture of Safety and High
Reliability Organizations.
II.
The Center for Transforming Healthcare.
III.
Evidence-Based Requirements: The HAI-Focused NPSG &
the Compendium.
IV.
NPSG 07.04.01 Central Line-Associated Blood Stream
Infections (CLABSI).
V.
Survey Issues for NPSG 07.04.01 CLABSI.
VI.
Summary
VII.
Questions & Answers
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Presentation Outline
Culture of Safety and High Reliability
Organizations (HRO)
– Goal to promote a “Culture of Safety” in accredited health
care organizations (HCO)
 Standards
 National Patient Safety Goals
 Reporting of Sentinel Events
 Expectation of Root Cause Analysis
 Core measures
 Nudging hospitals towards becoming a High
Reliability Organization (HRO).
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 The Joint Commission’s vision: 2009, 2010, and
beyond:
Culture of Safety and High Reliability
Organizations
Definition of an HRO: An organization that has
succeeded in avoiding catastrophes in an
environment where normal accidents can be
expected due to risk or complexity.
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Movement Towards a HRO
Culture of Safety and High Reliability
Organizations
Preoccupation with failure
Reluctance to simplify interpretation of
problems
Sensitivity to operations
Commitment to resilience
Deference to expertise
*Source: Agency for Healthcare Research and Quality. Transforming Hospitals into High Reliability Organizations.
Rockville. MD: AHRQ. Available online at: http://www.ahrq.gov/qual/hroadvice/hroadviceexecsum.htm
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5 Characteristics of HRO
Culture of Safety and High Reliability
Organizations
Two organizational processes that
impact HRO status & a culture of safety:
Medication management
Center for Transforming Healthcare
Standards
National Patient Safety Goals (NPSG)
Compendium
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Infection prevention & control
Culture of Safety and High Reliability
Organizations
“Target Zero”
Goal: Virtual elimination
of sentinel events,
never events, & accidents
TIME
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Occurrence
Culture of Safety and High Reliability
Organizations
“Target Zero”
Goal: Virtual elimination
of sentinel events,
never events, & accidents
Goal: Culture of Safety
Achieved
and
Sustained
TIME
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Occurrence
Culture of Safety and High Reliability
Organizations
Culture of Safety-Standard LD-03.01.01:
Leaders create and maintain a culture of safety and
quality throughout the organization.
Standard LD: 03.02.01
Standard LD: 03.05.01
Leaders implement changes in existing processes to
improve the performance of the organization.
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The hospital uses data and information to guide decisions
and to understand variation in the performance of
processes supporting quality and safety.
Evidence-Based Requirements
 The Joint Commission is prepared to transform science
into evidence-based requirements (i.e. standards and
NPSG).
 A culture of safety and high reliability organizations must
rely on evidence-based requirements in healthcare.
 Standards and NPSG are to be value driven:
Implementation with a reasonable expenditure of resources.
 The HAI-focused NPSG are one example.
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 The Joint Commission’s goal is to have the standards and
National Patient Safety Goals (NPSG) evidence-based.
The Joint Commission’s
Center for
Transforming Healthcare
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(http://www.centerfortransforminghealthcare.org/about/about.aspx?)
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The Joint Commission’s
HAI-Focused NPSG
and
The Compendium of Strategies to
Prevent Healthcare-Associated
Infections in Acute Care Hospitals
Development of the Compendium
 The HAI*-Allied Task Force was initiated by:
– Society of Healthcare Epidemiology in America (SHEA)
– Infection Disease Society of America (IDSA)
 Primary partners include:
– American Professionals in Infection Control (APIC)
– The American Hospital Association (AHA)
– The Joint Commission
 Compendium was published in October 2008
– Online: http://www.shea-online.org/about/compendium.cfm
Special edition in SHEA’s journal: Infection Control and
Epidemiology , Volume 29, Supplement 1
*Healthcare Associated Infections
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 Work of the Task Force began in December 2006
Components of the Compendium
The Compendium was developed for 6 common HAI
including:
1. Clostridium difficile infections (CDI)
2. Methicillin-resistant S. aureus (MRSA)
3. Central line-associated bloodstream
infections (CLABSI)
4. Catheter-associated urinary tract infections
(CAUTI)
5. Surgical site infections (SSI)
6. Ventilator-associated pneumonia (VAP)
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
What’s different about the Compendium?
 What’s different about the Compendium?
 Compendium was published in October, 2008
– Special edition in SHEA’s journal: Infection Control and
Epidemiology , Volume 29, Supplement 1
– Online: http://www.shea-online.org/about/compendium.cfm
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– The Compendium includes the first aggregation of evidencebased recommendations for the 6 HAI with an implementation
focus.
– Collaborative effort involving:
 Experts in infection prevention
and control: SHEA, IDSA, APIC
 The Joint Commission
 American Hospital Association (AHA)
– Endorsed and supported by a variety of organizations
– Focuses on accountability
The HAI-Focused NPSG
2009 HAI NPSG
NPSG.07.04.01: Implement evidence-based
guidelines to prevent central line–associated
bloodstream infections.
NPSG.07.05.01: Implement best practices for
preventing surgical site infections.
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NPSG.07.03.01: Implement evidence-based
practices to prevent health care–associated
infections due to multidrug-resistant organisms in
acute care hospitals.
Compendium and NPSG Comparison
1. Strategies to prevent Central line
associated bloodstream infections
NPSG 07.04.01 Implement evidence-based
guidelines to prevent central line–associated
bloodstream infections.
2. Strategies to prevent Ventilator
associated pneumonia
No
3. Strategies to prevent Catheterassociated urinary tract infections
No
4. Strategies to prevent Surgical site
infections
NPSG 07.05.01 Implement best practices for
preventing surgical site infections.
5. Strategies to prevent Methicillinresistant S. aureus
NPSG 07.03.01 Implement evidence-based
practices to prevent health care–associated
infections due to multidrug-resistant organisms
in acute care hospitals.
6. Strategies to prevent Clostridium
difficile infections
NPSG 07.03.01 Implement evidence-based
practices to prevent health care–associated
infections due to multidrug-resistant organisms
in acute care hospitals.
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2009 HAI NPSG
(Full implementation 1/1/2010)
Compendium Strategies
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2009 NPSG 07.04.01
Central Line-Associated
Blood Stream Infections (CLABSI)
2009 NPSG 07.04.01: Prevent Central Line–
Associated Bloodstream Infections
– Elements of performance (EP) 1 through 4 are the
2009 phase-in requirements with key milestones.
– EP 6 through 9 focus on organizational process
requirements (i.e. education, reporting).
– EP 10 through 15 focus on central line insertion
requirements.
– EP 16 and 17 focus on post insertion care.
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Key Points for NPSG 07.04.01 (2009)
2009 NPSG 07.04.01: Prevent Central Line–
Associated Bloodstream Infections
NPSG.07.04.01 Implement evidence-based practices to prevent
central line–associated bloodstream infections.
Elements of Performance for NPSG.07.04.01
1. As of April 1, 2009, the hospital’s leadership has assigned responsibility for
oversight and coordination of the development, testing, and implementation
of NPSG 07.04.01.
3. As of October 1, 2009, pilot testing in at least one clinical unit is under way
for the requirements in NPSG 07.04.01.
4. As of January 1, 2010, the elements of performance in NPSG 07.04.01 are
fully implemented across the organization.
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2. As of July 1, 2009, an implementation work plan is in place that identifies
adequate resources, assigned accountabilities, and a time line for full
implementation of NPSG 07.04.01 by January 1, 2010.
2009 NPSG 07.04.01: Prevent Central Line–
Associated Bloodstream Infections
5. As of January 1, 2010, the hospital educates health care workers
who are involved in these procedures about health care-associated
infections, central line–associated bloodstream infections and the
importance of prevention. Education occurs upon hire, annually
thereafter, and when involvement in these procedures is added to
an individual’s job responsibilities.
7. As of January 1, 2010, the hospital implements policies and
practices aimed at reducing the risk of central line–associated
bloodstream infections that meet regulatory requirements and
are aligned with evidence-based standards (for example, the
Centers for Disease Control and Prevention (CDC) and/or
professional organization guidelines).
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6. As of January 1, 2010, prior to insertion of a central venous
catheter, the hospital educates patients and, as needed, their
families about central line–associated bloodstream infection
prevention.
2009 NPSG 07.04.01: Prevent Central Line–
Associated Bloodstream Infections
8. As of January 1, 2010,the hospital conducts periodic risk
assessments for central line–associated bloodstream infections,
measures central line–associated bloodstream infections rates,
monitors compliance with evidence-based practices, and evaluates the
effectiveness of prevention efforts.
9. As of January 1, 2010, the hospital provides central line–associated
bloodstream infection rate data and prevention outcome
measures to key stakeholders, including leaders, licensed
independent practitioners, nursing staff, and other clinicians.
11. As of January 1, 2010, perform hand hygiene prior to catheter
insertion or manipulation.
12. As of January 1, 2010, for adult patients, do not insert catheters into
the femoral vein unless other sites are unavailable.
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10. As of January 1, 2010, use a catheter checklist and a standardized
protocol for central venous catheter insertion.
2009 NPSG 07.04.01: Prevent Central Line–
Associated Bloodstream Infections
13. As of January 1, 2010, use a standardized supply cart or kit that
is all inclusive for the insertion of central venous catheters.
14. As of January 1, 2010, use a standardized protocol for maximum
sterile barrier precautions during central venous catheter insertion.
16. As of January 1, 2010, use a standardized protocol to disinfect
catheter hubs and injection ports before accessing the ports.
17. As of January 1, 2010, evaluate all central venous catheters routinely
and remove nonessential catheters.
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15. As of January 1, 2010, use a chlorhexidine-based antiseptic for skin
preparation during central venous catheter insertion in patients over 2
months of age, unless contraindicated.
Using the HAI NPSG & Compendium Together
The Compendium provides additional
clinical detail to the requirements in
the NPSG.
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The HAI NPSG were based on the
implementation strategies described
in the Compendium.
Relationship of NPSG to the Compendium
NPSG 07.04.01
 EP 14. As of January 1, 2010, use a standardized
protocol for maximum sterile barrier precautions
during central venous catheter insertion.
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 NPSG.07.04.01: Implement evidence-based guidelines
to prevent central line–associated bloodstream
infections.
Relationship of NPSG to the Compendium
B. At insertion
5. Use maximal sterile barrier precautions during
CVC insertion (A‐I).
a. Use maximal sterile barrier precautions.
i. A mask, cap, sterile gown, and sterile
gloves are to be worn by all healthcare
personnel involved in the catheter
insertion procedure.
ii. The patient is to be covered with a large
sterile drape during catheter insertion.
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Compendium-CLABSI
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Survey Issues
For NPSG
07.04.01-CLABSI
Survey Issues
Surveyors will use the Compendium as
an educational resource through the
remainder of 2009, 2010 and beyond.
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Surveyors will survey the HAI-Focused
NPSG not the Compendium.
Frequently asked Question (FAQ) On
NPSG 07.04.01 CLABSI
Whole-house surveillance
Q. Must we perform surveillance on all central lines, or is targeted
surveillance okay?
A. Infection surveillance must be performed on all central lines; these lines
carry significant risk of morbidity and mortality regardless of
circumstances. Limiting surveillance to certain types of lines, patient care
units or service lines is not allowable under NPSG.07.04.01.
A. EP 10 requires use of “a catheter checklist and a standardized protocol for
central venous catheter insertion” The checklist or protocol is not required
to be a part of the patient’s medical record. A simple indication that the
checklist or protocol was completed, perhaps via a checkbox or brief note,
is sufficient.
EP 16 requires use of a “standardized protocol to disinfect catheter hubs
and injection ports before accessing the ports”. This is not a patientspecific documentation requirement. Surveyors will ask to see each
organization’s protocol; this may be in the form of a policy, protocol, etc
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Documentation
Q. Please explain the documentation icons for EPs 10 and 16. What
will surveyors expect to see?
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Summary
Education on the HAI-Focused NPSG
 An HAI-focused NPSG has been developed by The
Joint Commission and Joint Commission Resources
for accredited and certified organizations
 Title: HAI: From the Bedside to C-Suite
 Focus is on achieving compliance with the HAIfocused NPSG
 Available at:
http://www.jointcommissionconnect.org/
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 Features Louise Kuhny and Barb Soule
Key Points
Summary
– The Joint Commission’s focus: High reliability organizations and a
“culture of safety” are required to sustain the elimination of HAI.
– The Joint Commission is prepared to transform science into value
driven requirements and has successfully done so with the HAIfocused NPSG.
– The Joint Commission recently launched The Center for Transforming
Healthcare.
– The Joint Commission’s HAI-focused NPSG and the Compendium can
be used together as a strategy for reducing HAI in your organization.
– The Joint Commission and Joint Commission Resources recently
developed a webinar focusing on the HAI NPSG.
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– The Compendium includes the first aggregation of evidence-based
recommendations for the 6 HAI in an implementation format.
Summary
Compendium
Web address:
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http://www.shea-online.org/about/compendium.cfm
Summary
Kelly L. Podgorny RN, MS, CPHQ
Project Director
Division of Standards and Survey Methods
The Joint Commission
Telephone: 630-792-5108
E-mail: KPodgorny@jointcommission.org
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The Joint Commission
Contact Information: