Millennium and JCI Prevention and Control of Infection Accreditation Standards September 1, 2008 Introduction The purpose of this white paper is to present Cerner’s opinions concerning how it believes Millennium and associated solutions can potentially support the efforts of clients to comply with many of the standards contained in the Prevention and Control of Infection (PCI) section (pp. 155-166) of the 2007 Joint Commission International (JCI) Accreditation Standards for Hospitals, 3rd Edition (effective January 2008). The white paper and the information and opinions it contains have not been reviewed or endorsed in any way by JCI. While every effort was made to ensure the accuracy and completeness of information in the white paper when it was published, it should be used only for reference purposes. Interested parties should contact Cerner directly to obtain the most up-todate information concerning solution offerings and functionality, and to discuss how they might be used to address specific JCI standards. General Focus of the Standards The general focus of the accreditation standards in this area can be summarized as follows: - - - That the healthcare provider have an institution-wide infection control program in place to minimize the risk of development of healthcare associated infections That such a program be able to identify risks for acquisition and transmission of infectious agents on an ongoing basis That such a program be integral to ongoing operations within the institution, and be supported and collaborated in by representatives from relevant components or functions within the organization That leadership support such a program, and provide adequate resources to it That such a program be evaluated for effectiveness on an ongoing basis, and subject to continuous improvement as may be required o That this evaluation include ongoing monitoring and surveillance activities That the provider have a plan to respond to a large influx of infectious patients in emergency situations Millennium’s Role in Enabling Compliance Most of the standards found within this section of the JCI accreditation standards are supported by policy and procedure, education and training, and by surveillance, monitoring, and reporting activities carried out by the Infection Control function within a provider organization. However, there are some key system roles that Millennium can play in support of these activities. At a summary level, these can include: Cerner Corporation Confidential Information ©Cerner Corporation. All rights reserved. This document contains confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. - Contributing data to the identification and reporting of infectious outbreaks Providing reporting to support the analysis and trending of past infectious outbreaks The solution key to supporting these standards is PathNet Microbiology. Note: The solutions, solution functionality, and services referenced in this white paper may not be available in all markets. At a more granular level, Millennium can assist in enabling compliance with these standards in the ways described below. (Specific JCI accreditation standards are stated followed by the abilities of Millennium to enable compliance.) The JCI standards that are highlighted for comment are those that seem to most directly imply a system role in compliance. Program Leadership and Coordination PCI.1 – One or more individuals oversee all infection prevention and control activities. This individual(s) is qualified in infection control practices through education, training, experience, or certification. One or more individuals oversee the infection control program. The individual(s) is qualified for the organization’s size, level of risks, and program scope and complexity. The individual(s) fulfill program oversight responsibilities as assigned or described in a job description. The system does not play a direct role in meeting this standard. However, Millennium can help document the qualifications (e.g., licensure, accreditation, education, registration) of individuals as health care professionals. PCI.2 – There is a designated coordination mechanism for all infection control activities that involves physicians, nurses, and others as appropriate to the size and complexity of the organization. There is a designated mechanism for the coordination of the infection control program. Coordination of infection control activities involves physicians. Coordination of infection control activities involves nurses. Coordination of infection control activities involves the infection control professionals. Coordination of infection control activities involves others as appropriate to the organization. The system does not play a direct role in meeting this standard, aside from that outlined in the response to PCI.5. However, the common database within PathNet Microbiology supports the long-term storage of results online, making data available throughout the organization. This can help facilitate involvement in infection control by individuals in many different venues and roles in the organization. Cerner Corporation Confidential Information ©Cerner Corporation. All rights reserved. This document contains confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. PCI.3 – The infection control program is based on current scientific knowledge, accepted practice guidelines, and applicable law and regulations. The infection control program is based on current scientific knowledge. The infection control program is based on accepted practice guidelines. The infection control program is based on applicable law and regulation. See other sections for system role. The system does not play a direct role in meeting this standard. However, the Executable Knowledge solution offers a module on infectious disease that provides information on current scientific knowledge in this area. In addition, Cerner’s nursing solutions can support documentation of evidence-based practice to improve outcomes in high-risk areas for infection (e.g., ICU). PCI.4 – The organization’s leaders provide adequate resources to support the infection control program. Information management systems support the infection control program. The system would not directly provide reporting for this purpose, but would provide support for statistics on previously identified infectious outbreaks as may be supported by the same data as underlies the reporting above. Focus of the Program PCI.5 – The organization designs and implements a comprehensive program to reduce the risks of health care-associated infections in patients and health care workers. There is a comprehensive program and plan to reduce the risk of health care-associated infections in patients. There is a comprehensive program and plan to reduce the risk of health care-associated infections in health care workers. The program includes systems to investigate outbreaks of infectious diseases. (Also see International Patient Safety Goal 5, ME 1) Risk-reduction goals and measurable objectives are established and regularly reviewed. The system can contribute to infection surveillance from within Microbiology for reporting of statistics of infectious outbreaks – the system does not directly help enable prevention or control of infection. The system can provide for statistical reporting on outbreaks based on the infectious agents, patients, patient locations, time of infection, and other relevant factors to support preliminary identification of possible patterns of outbreak. Cerner Corporation Confidential Information ©Cerner Corporation. All rights reserved. This document contains confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. Cerner’s nursing solutions can support documentation of evidence-based practice to improve outcomes in high risk areas for infection (e.g, ICU). Specific tasks, or care protocols can be implemented and adhered to, and the data collected for these protocols can support outcomes measurements. Cerner content includes IHI Ventilator bundles, and Central Line bundles to manage patients who are at higher risk for pneumonia and bloodstream infections due to use of devices such as ventilators and central lines in the course of care. Through Cerner’s Lighthouse service bundles, Cerner can assist in modeling certain clinicalor conditions-based processes and through PowerInsight, provide measurement support for identifying possible gap areas. Ongoing monitoring can be supported through PowerInsight to help provide support for measuring improvement in outcomes. Through this process, Lighthouse services that leverage process modeling can help identify the current state, define a future state, support measurement of outcomes at relevant points in time to establish a basis of comparison (through PowerInsight), and Cerner can provide recommended clinical and decision support content at key points of decision making in a given process to affect necessary changes for improving performance. Infectious disease-related areas identified for current or planned Lighthouse services include Infection Control Surveillance and Risk Management, Surgical Site Infections (coronary artery bypass graft (CABG) and electives), Catheter-Related Infections (urinary tract and vascular), Sepsis, Ventilator-Associated Pneumonia, and Community-Acquired Pneumonia. PCI.6 – The organization establishes the focus of the health care-associated infection prevention and reduction program. The organization has established the focus of the program to prevent or reduce the incidence of health care-associated infections. Respiratory tract infections are included as appropriate to the organization. Urinary tract infections are included as appropriate to the organization. Intravascular invasive devices are included as appropriate to the organization. Surgical wounds are included as appropriate to the organization. Epidemiologically significant diseases and organisms are included as appropriate to the organization and its community. Emerging or reemerging infections are included as appropriate to the organization and its community. The system can enable reporting of statistics on key data elements useful for monitoring and surveillance as mentioned in PCI.5 above. PCI.7 – The organization identifies the procedures and processes associated with the risk of infection and implements strategies to reduce infection risk. The organization has identified those processes associated with infection risk. (Also see MMU.5, ME 1) Cerner Corporation Confidential Information ©Cerner Corporation. All rights reserved. This document contains confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. The organization has implemented strategies to reduce infection risk in those processes. (Also see MMU.5, ME 1) The organization identifies which risks (also see PCI.7.1 through PCI.7.5) require policies and or procedures, staff education, practice changes, and other activities to support risk reduction. The system’s role is as stated in response to PCI.5. PCI.7.1 – The organization reduces the risk of infections by ensuring adequate equipment cleaning and sterilization and the proper management of laundry and linen. When single-use devices and materials are reused, there is a policy that includes items a) through e) in the intent statement, and the policy is implemented. [NOTE: The following section is from the intent statement.] The policy includes identification of a) devices and materials that can never be reused; b) the maximum number of reuses for devices and materials that are reused; c) the types of wear, cracking, etc., that indicate the device cannot be reused; d) the cleaning process for devices that starts immediately after use and follows a clear protocol; and e) the process for the collection, analysis and use of infection control data related to reused devices and materials. There is a coordinated oversight process for all cleaning, disinfection and sterilization throughout the organization. Millennium does not play a direct role in the cleaning and sterilization of equipment and supplies. However the ProCure solution can be used to track the location of consumable supplies, as well as reusable materials, instruments, and equipment, which can support efforts to coordinate cleaning, disinfection, and sterilization activities and identify potential sources of infection. Development projects planned for the near future involve enhancements to ProCure functionality that will allow supplies, instruments, and equipment to be tracked and monitored as to their state of readiness for use, including detailed information about sterilization, cleaning, and maintenance status. This information can then be tied into scheduling functions to indicate the availability of these resources for use. The system will also be able to provide alerts to clinicians when they attempt to schedule or use supplies, instruments, and equipment that are not in an appropriate state for use because they are unsterilized, unclean, require maintenance, etc. RFID technology will enable the tracking of consumable and reusable supplies in a specific space, such as the OR, to aid decision-making regarding their efficient and appropriate use. PCI.7.2 – The organization reduces the risk of infections through proper disposal of waste. Cerner Corporation Confidential Information ©Cerner Corporation. All rights reserved. This document contains confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. Disposal of infectious waste and body fluids are [sic] managed to minimize transmission risk. The handling and disposal of blood and blood components are managed to minimize transmission risk. The system can track specimens, including those considered infectious waste and body fluids, from patient to secondary sites (e.g., laboratories) and then to final disposition. The system does not play a role in documenting details of final disposition (e.g., how, when, by whom) as this is something that a hospital would normally document through separate record-keeping processes. Through Blood Bank Transfusion in PathNet, the system can track blood components from the time their barcodes are scanned and they enter inventory through to storage and then administration to patients or disposition. The system does not record the details of final disposition, only the fact that the product has been disposed. If a blood-borne infection is suspected, the pathway the blood product in question has taken from first being received can be traced, thereby supporting efforts to identify and minimize potential transmission risks. In addition, PowerForms can support blood tracking efforts by enabling a caregiver to document the fact that a particular unit of blood (ID number) was administered to a particular patient. Isolation Procedures PCI.8 – The organization provides barrier precautions and isolation procedures that protect patients, visitors and staff from communicable diseases and protects immunosuppressed patients from acquiring infections to which they are uniquely prone. Patients with known or suspected contagious diseases are isolated in accordance with organization policy and recommended guidelines. Policies and procedures address the separation of patients with communicable diseases from patients and staff who are at greater risk due to immunosuppression or other reasons. The organization has a strategy of dealing with an influx of patients with contagious diseases. Appropriate negative pressure rooms are available and monitored routinely for infectious patients who require isolation. Staff are educated in the management of infectious patients. The system does not play a direct role in meeting this standard. However, Microbiology can generate Infection Control Candidate reports used to determine which patients need to be monitored for infection control purposes. Patients can qualify for the report based on their demographics, procedure information, report responses, susceptibility results, or general laboratory results. Cerner Corporation Confidential Information ©Cerner Corporation. All rights reserved. This document contains confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. Isolation requirements for a particular patient can be documented through the system at registration or later, making this information available through the patient’s EMR to system users. These requirements can be coded differently (e.g., airborne risk vs. physical contact risk, etc.), and the system can provide alerts about them to caregivers, through bed board management functionality, when they attempt to place another patient in close proximity (e.g., the same room) to a patient subject to isolation protocols. Caregivers can accept or override these alerts by documenting a reason for this decision. In addition, if an order for isolation is made through the system, reference text can be attached to this that contains whatever information about isolation procedures, etc., the caregiver or hospital chooses to include. Integration of the Program with Quality Improvement and Patient Safety PCI.10 – The infection control process is integrated with the organization’s overall program for quality improvement and patient safety. Infection control activities are integrated into the organization’s quality improvement and patient safety program. See other responses above as to system role. PCI.10.1 – The organization tracks infection risks, infection rates, and trends in health careassociated infections. Health care-associated infection risks are tracked. Health care-associated infection rates are tracked. Health care-associated infection trends are tracked. See response to PCI.5. The system can enable reporting that can contribute to review of ongoing levels of infection in given areas and locations (nurse unit, facility, bed, etc.) over time, but the user would need to know the target of the review for purpose of analysis – the system does not enable definition of specific effectiveness objectives and monitoring within its reporting. PCI.10.2 – Monitoring includes using indicators related to infection issues that are epidemiologically important to the organization. Infection monitoring uses indicator measures. The indicators measure epidemiologically important infections. The system does not play a direct role aside from that outlined in responses to PCI.5 and PCI.10.1. PCI.10.3 – The organization uses risk, rate, and trend information to design or modify processes to reduce the risk of health care-associated infections to the lowest possible levels. Cerner Corporation Confidential Information ©Cerner Corporation. All rights reserved. This document contains confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner. Processes are redesigned based on risk, rate, and trend data and information. Processes are redesigned to reduce infection risk to the lowest levels possible. The system does not play a direct role in this requirement aside from that described in PCI.5 in reference to Lighthouse process optimization. PCI.10.4 – The organization compares its health care-associated infection rates with other organizations through comparative databases. Health care-associated infection rates are compared to other organizations’ rates through comparative databases. (Also see QPS.4.2, ME 2 and MCI.20.3, ME 3) The organization compares its rates to best practices and scientific evidence. The system does not play a direct role in this activity. PCI.10.5 – The results of infection monitoring in the organization are regularly communicated to leaders and staff. Monitoring results are communicated to medical staff. Monitoring results are communicated to nursing staff. Monitoring results are communicated to management. The system does not currently play a direct role in reporting of this kind. PCI.10.6 – The organization reports information on infections to appropriate external public health agencies. Infection control program results are reported to public health agencies as required. The system does not play a direct role in meeting this standard. Education of Staff about the Program PCI.11 – The organization provides education on infection control practices to staff, doctors, patients, and, as appropriate, family and other caregivers. The system does not play a direct role in this requirement. However, as previously mentioned, Learning Manager can be used to help document, track, and assess an individual's education and training as well as help plan and manage learning events to create, maintain, or enhance specific competencies. Cerner Corporation Confidential Information ©Cerner Corporation. All rights reserved. This document contains confidential and/or proprietary information which may not be reproduced or transmitted without the express written consent of Cerner.