Infection Prevention

1
Infection Prevention Control Participates in an
Accreditation Pilot

• Nancy Peddle MLT CIC
• St. Josephs Healthcare
• Hamilton

2
The Issue

• Canadian Council on Health Services Accreditation
  (CCHSA)
• New process
• New standards
• Required Organizational Practices (ROPs)
• Self Assessment Questionnaire

3
A Pilot.This is our test flight

• How are we doing?
• Has our message been received?

4
1 Review Infection Control Standards

• Reviewed new CCHSA Infection Control Standards
• Reviewed Required Organizational Practices
  (ROPs)
• Involved Infection Prevention Control Quality
  Council

5
2 Distribute the Infection Control Survey

• 28 Questions
• 99 Frontline staff surveyed
• 34 response rate
• 17 red flags!!

6
The Survey

• Each question had 3 choices
• A Cant Rate column
• A Perceived Priority column

7
Flags

• Red Flag lt80 responses in column 3
• Green Flag
• gt 80 responses in column 3

8
3 Develop Action Plan

• Addressed red and yellow flags
• Updated in stages
• Showed evidence of progress
• Provided indicators for success

9
4 Infection Control ROPs and Indicators

• 6 Infection Control ROPs
• Infection rates
• Policies Procedures
• Hand Hygiene education
• Influenza Vaccination Policy
• Pneumococcal Vaccination Policy
• Sterilization processes
• Indicators
• MRSA/C. difficile rates
• SSIs and timely prophylactic antibiotics

10
5 The On-Site Visit

• Met with surveyor
• Review of program
• FEEDBACK!!

11
The Challenges

• Ambiguous nature of some survey questions
• The red flags (17 !!!)
• On-site visit resulted in different conclusion
• CCHSA formula changed and red flags became yellow
  flags

12
The Opportunities

• Head start with new process
• Infection Control program assessment
• Stronger communication links
• Frontline staff involvement
• Valuable feedback from surveyors
• Continuous quality improvement

13
Questions
14
Thank you

• Infection Prevention Control
• Ruth Stevenson
• May Griffiths-Turner
• Susan Lessard
• Quality Performance Improvement
• Ann Higgins
• Joey Hrebik