Infection Prevention & Quality Improvement Tips

December 2021

By Jody Randall MSN, RN, CIC, HACP-CMS, HACP-PE

CEO and Founder

We would like to take a moment to raise awareness to the following healthcare related events for December 2021: World AIDS Day – Dec. 1, National Handwashing Awareness Week – Dec. 5-11 and National Influenza Vaccination Week. We wish all of our hard working healthcare professionals out there a joyous holiday season from HCE!

Greetings

We hope that everyone is enjoying a wonderful, joyous and peaceful holiday season. Thank you for your ongoing support. We are committed to helping healthcare organizations achieve and maintain ongoing service excellence. We commend all of you for your commitment to quality improvement and patient safety. Each month, we share helpful tips which are based upon ongoing observations by our HCE professionals. We find that these topics are not often understood. Therefore, we share information that we hope will help others.


Infection Prevention Tips

Transportation is typically not the first thing that comes to mind when discussing infection prevention matters. In the world of healthcare however, these two topics are often directly related. It is not uncommon for healthcare facilities to transport instruments or equipment between multiple inter-organizational locations. Facilities can reduce costs by sharing resources such as personnel and equipment. It is important to keep in mind that these practices must comply with AAMI, ANSI, DOT and OSHA standards. It is critical for organizations to develop policies and procedures that meet all requirements. It is also critical to ensure that team members who will be involved in the transporting process are properly trained and have been deemed competent to perform these tasks in a safe and compliant manner.

Vehicles used in the transporting equipment must have a clear separation between clean and dirty items. It is also important to ensure that items being transported are properly labeled. Instruments soiled with blood or bodily fluids should be transported in containers appropriately labeled as "Biohazard". When selecting containers for transport, be sure to choose containers that are leak proof as well as puncture proof. Vehicles transporting soiled instruments should also be equipped with personal protective equipment and spill kits. Be sure to review your state's specific DOT requirements. Vehicles must also be able to maintain acceptable temperature and humidity ranges. Extreme heat or humidity levels can compromise the integrity of sterile instruments which increases risk of infection if instruments are then used in patient care.

We recommend reviewing your facility's current workflow for transporting instruments between facilities. Be sure to develop, review or revise existing policies to ensure current practices are compliant with regulating agencies. Evaluate workflows and interview employees to ensure that they are following safe practices and have a good understanding of your organization's policies and procedures concerning transportation of medical instruments and equipment.

Healthcare Quality Improvement Tips

A Workplace Violence Prevention Program should be included as part of your organization's Quality Assurance Performance Improvement Plan. There are a variety of factors that exist in a healthcare setting that promote an increased risk for workplace violence to occur. Holidays, although joyous, are also stressful at times. This is why we decided to include workplace violence as a topic in our monthly newsletter to raise awareness about workplace violence.

In order to have an effective Workforce Violence Prevention Program, you must have team members who are well educated about the risk factors and appropriate response methods when faced with potentially violent situations. Such situations when they arise tend to escalate very quickly so effective and timely response to these matters are critical. The National Institute for Occupational Safety and Health (NIOSH) offers plenty of free educational materials that can be utilized for training purposes. Active shooter incident planning should also be incorporated into your Emergency Preparedness Plans. Free training materials are easily available through the Department of Homeland Security. You can also consult the Regional Advisory Committee (RAC) in your area for training help and support.

In order to have an effective Workplace Violence Prevention Program, organizational leaders must be invested in promoting the plan by providing a comprehensive education program for all team members and performing drills within the organization. This will help employees be better prepared when faced with these unfortunate and horrifying events.

A few key points to include within your program are education on awareness of behavior that can lead to violence, training employees on how to respond when faced with potentially violent situations, training employees on how to elicit help a situation arises, review of escape routes for employees to safely remove themselves from a situation if necessary and how to barricade themselves for protection if unable to escape and an active shooter has entered the building. We recognize that the concern for violence in the workplace is very real. It is up to each organization to do their part in keeping everyone safe. It is also important for all employees to feel safe on the job. Having an effective Violence Protective Program will ensure that team members feel secure and know exactly what to do when facing a hostile situation that arises.

In Summary

We hope that you find our tips helpful. Regretfully, in the healthcare industry, some of the topics that must be discussed can create a certain level of anxiety for healthcare workers. Ultimately, having well established policies, procedures and educational programs in place can help reduce anxiety across the board for the entire healthcare team.

Get in Touch

Here at HCE we recognize that there are so many challenges healthcare entities face on an ongoing basis and the healthcare climate is changing rapidly and drastically. We continue to encounter challenges as a result of the COVID-19 pandemic. Whether you are attempting to put your facility back on track or opening a new healthcare entity amongst these challenging times, you are likely managing a fair number of challenges. HCE can help! Contact one of our experts today. Tell us your needs and we will customize a plan to assist you and your organization eliminate your day-to-day operation stress. 

Happy holidays to you and yours from all of us here at HCE!

April 1, 2025
Behavioral health hospitals play a vital role in addressing mental health and substance use disorders, providing critical care to vulnerable populations. However, ensuring compliance with regulatory standards is a complex and ongoing challenge.
March 7, 2025
Providing respiratory care services can be a challenge for hospitals, especially during months when respiratory illnesses are at their peak throughout communities.
February 10, 2025
It is that time of year again. At least for acute care hospitals, long-term acute care (LTAC) hospitals and inpatient rehabilitation facilities (IRF) who report to The National Healthcare Safety Network (NHSN). If annual surveys are not reported by March 1 st , then your organization will not be permitted to enter monthly reporting plans until the annual survey has been completed. Although there are just a few weeks to go, early planning is the key. It is important to consider that responses to the Annual Survey questions are a collaborative effort. Planning a meeting in advance with key stakeholders will help to ease the stress of completing what some may consider to be a daunting task. Be sure to coordinate with Facilities Managers, Pharmacists, Laboratory, Nursing, Infection Prevention and Quality leaders on annual survey responses. Although individuals who are responsible for report submission may find that some of the data has not changed significantly from the previous year, we have identified that some questions have been removed while additional questions have been added. If you are new to NHSN reporting and have not yet completed an annual survey, you will find an alert reminding you on your dashboard upon logging in. Keep in mind that the survey you are completing requires data from the previous calendar year. You will be submitting data for 2024 due March 1 st , 2025. There are a variety of questions that will require information about metrics, facility type, infection prevention practices, laboratory testing methods, water quality management, and antimicrobial stewardship practices for example. Instructions on completing your organization’s annual survey click on the link below that corresponds with your facility type: Instructions for Completing Annual Hospital Survey Instructions for Completing LTAC Annual Survey Instructions for Completing IRF Annual Survey OSHA requires the following facilities to complete an annual occupational injury and Illness Report: Ambulatory Health Care Servies General Medical and Surgical Hospitals Psychiatric and Substance Abuse Hospitals Specialty Hospitals Skilled Nursing Facilities For a complete list of facilities required to report annually via electronic submission and for additional information on Standard 1904 Subpart E Appendix B click on the following link: OSHA Injury and Illness Reporting Requirements . Much like NHSN annual surveys, this reporting is also for the prior calendar year. Your deadline for submission is March 2, 2025. If your organization has not previously been reporting, please note that you will need to set up an Injury Tracking Application (ITA) account. For complete instructions, click on the following link User Guide . Individuals who are responsible for report completion and submission should have a clear understanding of criteria that constitutes a work-related injury. They will also need to know if the employee missed days of work because of injury or illness. If an employee was restricted from usual work activities or reassigned to a new role as a result of the injury or illness this information must be documented. If an employee required care beyond basic first aid, this will also need to be reported. Reporters should not include Protected Health Information (PHI). For a brief tutorial on OSHA annual reporting requirements, click on the following link OSHA Injury and Illness Reporting . Our experts understand the challenges that all healthcare facilities are facing today. Using a customizable approach, we will help you navigate through even the toughest of challenges. Whether you are in need of mock surveys, leadership training, corrective action plans or ongoing support services, we can help! We pride ourselves on helping our clients achieve and maintain a status of excellence in the healthcare industry. Be sure to browse Our Website for a full list of services we provide. Contact us today at +1 (800) 813-7117 to schedule a free consultation. References: https://www.cdc.gov/nhsn/forms/instr/57_103-toi.pd https://www.osha.gov/laws-regs/regulations/standardnumber/1904/1904SubpartEAppB https://www.osha.gov/sites/default/files/ita_user_guide.pdf https://www.osha.gov/sites/default/files/osha_rktutorial.pdf