General Acute Care Hospital Relicensing Survey GACHRLS Lisa

General Acute Care Hospital Relicensing Survey (GACHRLS) Lisa Kilgore, MBA-HCM, BSBM, CIC Manager Epidemiology Scripps Memorial Hospital Encinitas 11/9/16

Objectives • Understand what is the General Acute Care Hospital Relicensing Survey (GACHRLS) • How to prep for the GACHRLS • How Infection Preventionist can be a resource during and after survey

What is a GACHRLS? ? The California Department of Public Health (CDPH) developed the General Acute Care Hospital Relicensing Survey (GACHRLS) in order to work smarter with limited staff. GACHRLS is a combination of: • Medication Error Reduction Plan (MERP) • Patient Safety Licensing Survey (PSLS) • Title 22 California Hospital Regulation

Why More Torture? • • Required by statute of Health & Safety Code Section 1279 (a) Promote and ensure quality of care in hospitals Verify compliance with State statutes and regulations Ensure consistency in hospital survey methods BASICALLY TO PROVIDE US WITH 3 -5 DAYS OF ENDLESS TORTURE!!!!! BRING ON THE BABY

Infection Prevention Prep Update or develop an entrance list binder of documents • Infection Control Program • • All policies and procedures are updated Review ICC minutes Review all patients in all Precautions (know SB 1058) Hand hygiene program Cleaning, disinfection and sterilization of equipment OR / SPD / ENDO NHSN (SSI, VAE, HAI, LABID)

DAYS 1 -4 During the opening session, the lead surveyor introduced herself and her team which consisted of: • 1 Pharmacist • 1 Physician Consultant (Pediatrician) • 4 Registered Nurses (RN)

DAYS 1 -4 Although only these 6 showed up at our door, any other hospital could also have the following: • Dietitian • Life Safety Code Surveyor • IC Specialist • Occupational Therapist • Consultants as needed • Records Administrator

DAY 1 -4 The lead surveyor stated that each surveyor would have a main focus: • 1 RN: Main OR and procedural areas (ENDO, PACU, PREOP, SPD) and any floor where these patients go after leaving any of the above areas • • 1 RN: L&D/Mother Baby/ NICU/OR 2 RN: Med/Surg, Rehab (inpt/outpt), Definitive Observation unit, ED Physician: Physician/Administration interviews, all units Pharmacist: All units and Pharmacy

IP Interview/Involvement • Infection Control Committee • Reviewed minute • Previous PSLS, TJC, CMS survey findings • Policies, procedures (staff compliance) • IP biggest issues (hand hygiene compliance) • Cleaning/sterilization/disinfecti on • MERP/QAPIC/Quality Council • ICC minutes/reporting to the above committees • Antimicrobial Stewardship

IC GACHRLS Almost Findings AFL 11 -32 reported procedures (who, what, when, how and how often) to what committees, outside hospitals, etc • Reviewed the Risk Assessment, minutes from the Surgery Supervisory committee and ICC to see what was reported and how often (Surgery Sup quarterly and PRN) • NHSN line listing of Denominator and Numerators • How do we know that we have infections (monthly SSI review (numerator)) • How do you know you catch all infections? (I don’t)

IC GACHRLS Almost Findings Cleaning/Disinfection: Know your cleaning supplies. What is cleaned and what is disinfected and how often • Inpatient equipment (Alaris pumps, glucometers etc) • Outpatient equipment (Rehab) Is the cleaner/disinfectant the same in the hospital? (outsourced, EVS, staff)

GACHRLS Survey Deficiency Action Plan • Your plan of action can be both temporary and permanent and should address the processes that lead to the deficiency cited. • Document the plan/procedure for implementing the plan of correction for the deficiency (what, how, when) • Have a monitoring process to ensure that the plan of correction is effective and the deficiency remains corrected (will not reoccur) and/or in compliance with regulatory requirements • Who is responsible for implementing the acceptable plan of correction? (Unit manager(not IP)) • Date when immediate corrective action will be completed. Normally not more than 30 calendar days from the date of the survey exit conference • Ensure that each deficiency/action plan is reported and documented to the appropriate committees (ICC, QAPIC, Quality, Safety)

IP GACHRLS Findings and Corrective Action Plan Neptune Drain: • In Central Sterile Processing Department had proper splash guard installed; however not anchored/no maintenance PM documented on the replacement of the box and no process of ownership as to who would request replacement when necessary • A monel wool was placed over the drain on 2/15/16 by engineering department • Monitoring of the PM to ensure compliance will done by manager of engineering during rounds in CPD once a week for the first month and then once a month for 2 months • The monitoring will start 2/15/16 and complete on 5/16/16 • Preventative maintenance of the wool covers will occur w/PM reports 2 x year to ICC and Safety committee

IP GACHRLS Findings and Corrective Action Plan Transport of Instruments: • The transport of soiled instruments from the OR to CPD does not meet hospital P&P for rigid container labeled with orange biohazard symbol. Know what is recommended and what is regulatory and make sure you follow what is in your policies or procedures • Proper transport containers were purchased by OR/CPD manager on 2/8/16 • OR/CPD manager will audit/observe 30 transports every month for 3 months to ensure utilization of new container and permanent application of biohazard label on outside of container with every transport • The new process will be monitored for 3 months starting 2/8/16 and will complete on 4/30/16 • Compliance will be reported at QAPIC for three months (April-June)

IP GACHRLS Findings and Corrective Action Plan PPE: • Employee entered Enhanced Contact Precautions (ECP) room without PPE violating hospital Standard and Transmission Based Precautions policy • Immediate education/reinforcement was performed by IP with Staff during huddles, standups and staff meetings regarding appropriate PPE • The Manager and Director will perform 30 audits/observations per month for 3 months (Feb-April). 90% compliance or higher to ensure compliance with process • The new process will be monitored for 3 months starting 2/2/16 ending 4/30/16 • Report out at Infection Control committee meeting 7/15/16

IP GACHRLS Findings and Corrective Action Plan Equipment labeled with clean stickers: • Clean equipment was inconsistently labeled with clean stickers • CPD and Supply chain staff went to each equipment room and ensured that clean labels were on all appropriate equipment. Re-education focused on the policy principle that all equipment that has been properly cleaned must have a “CLEAN” sticker placed on it. NO equipment is to be delivered without a “CLEAN” sticker • Weekly random audits will be done by CPD/OR/PACU/Supply Chain managers for six weeks beginning 2/2/16 with 100% compliance expected • The new process will be monitored for six weeks beginning 2/2/16 and ending 3/14/16 • Compliance will be reported at the 4/15/16 Infection Control Committee

References https: //www. cdph. ca. gov/programs/Ln. C/Pages/General. Acute. Care. Relicensing. Survey. as px • Relicensing survey overview • Process Guidelines • Regulations w/Survey Procedures • General Entrance List • Pharmacy Entrance List • Survey Activity Schedule • Medication Pass Worksheet • Relicensing Evaluation Form

Thank you!