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Tampilkan postingan dengan label The Joint Commission. Tampilkan semua postingan

Jumat, 08 April 2011

Joint Commission and Influenza Vaccination: IC.02.04.01

This seal in no way suggests that the
Joint Commission approves of this blog
The Joint Commission has just released proposed requirements addressing influenza vaccination of staff and licensed independent practitioners. Revisions to current requirements are proposed for Hospital, Critical Access Hospital, and Long Term Care accreditation programs with new requirements proposed for Ambulatory Care, Behavioral Health Care, Home Care, Laboratory, Medicare Based Long Term Care, and Office-Based Surgery accreditation programs.  Comments will be gathered until May 17, 2011.

You can review the proposed standards and leave comments on the JC site here.

For the Hospital Accreditation Program IC.02.04.01, elements 1-3 remain the same, elements 4 and 5 have been revised and elements 6-9 have been added. The new text is bolded below and the revised elements are:

1. The hospital establishes an annual influenza vaccination program that is offered to licensed independent practitioners and staff
2. The hospital educates licensed independent practitioners and staff about, at a minimum, the influenza vaccine; non-vaccine control and prevention measures; and the diagnosis, transmission, and impact of influenza. (See also HR.01.04.01, EP 4)
3. The hospital provides influenza vaccination at sites accessible to licensed independent practitioners and staff.

4. The hospital annually evaluates vaccination rates and the reasons given for declining the influenza vaccination.
4. The hospital includes in its infection control plan the goal of improving influenza vaccination rates. (For more information, refer to Standard IC.01.04.01)

5. The hospital takes steps to increase influenza vaccination rates.
5. The hospital sets incremental influenza vaccination goals, consistent with achieving the 90% rate established in the national influenza initiatives for 2020.

6. The hospital develops a written description of the methodology used to determine influenza vaccination rates. All hospital staff and licensed independent practitioners are to be included in the methodology for determining the influenza vaccination rates. (See also IC.02.04.01, EP 1)
7. The hospital evaluates the reasons given by staff and licensed independent practitioners for declining the influenza vaccination at least annually.
8. The hospital improves its vaccination rates according to its established goals and at least annually. (For more information, refer to Standards PI.02.01.01 and PI.03.01.01)
9. The hospital provides influenza vaccination rate data to key stakeholders including leaders, licensed independent practitioners, nursing staff, and other staff at least annually.

Kamis, 02 Desember 2010

Two new NPSGs from the Joint Commission target VAP and CAUTI

University of Iowa, Class of 2013
The Joint Commission has just released new National Patient Safety Goals for 2012-13 for full implementation by January 1, 2013.  They cover VAP and CAUTI in hospitals and LTCF and are open for public comment until 1/27/2011.  The strategies were published in the October 2008 SHEA Compendium in ICHE. 

Two comments: (1) I thought the world was going to end in December 12, 2012, so probably not much to worry about, apart from the world ending and (2) VAP may be going away in NHSN to be replaced by process measures, so I wonder how VAP outcomes will be tracked, as required, when no one can decide on a definition? I'm sure you have comments and they want to hear from you.

Note: It looks like even if the Mayans were wrong about 2012, we may still not make it through 2013.

Example for VAP, NPSG.07.06.01 in Hospitals requires 7 steps:
1) A plan
2) Hand hygiene before/after caring for ventilated patients
3) Semirecumbent position of patient
4) Regular antiseptic oral care
5) Daily weaning assessment
6) Daily sedation interruption
7) Measure VAP process measures and outcomes

Hospital Program draft versions of NPSG.07.06.01 (VAP) and NPSG.07.07.01 (CAUTI) (PDF)
LTC Program versions (PDF)
JC page that provides links for submitting comments.

h/t Marc Wright