Spreadsheet: 23bf2209-20d7-4ff5-b564-cc8a1da50e7e
Sheet: Sheet1

NPSG # | Deadline for Implementation | Text | Met/Not Met | Current status | Plan for Compliance | Comments
07.01.01 | N/A (previous NPSG, program is in place) | Comply with current WHO or CDC hand hygiene guidelines | Met | Hand Hygiene campaign in monitoring and reporting phase.  [NAME] compliance 75-85%. Policy in-date | N/A | Policy reflects CDC guidelines.  Campaign rolled out June 2007.  Observations continue monthly, and are reported to ICC, QIEC, EMB.
07.02.01 | N/A (previous NPSG, program is in place) | Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function related to a healthcare-acquired infection | Met | QSD cases and those coded for CMS non-reimbursement are reviewed monthly; SCHMRC cases referred by QI to [NAME] are reviewed; cases that may be related to HAI are sent to CEOC for consideration after review by [NAME], ID.
07.03.01 |  | Implement evidence-based practices to prevent healthcare associated infections due to multiple drug-resistant organisms in acute care hospitals |  |  |  | Evidence upon which CDC recommendations and IHI bundles (contact precautions, decolonization and active surveillance testing) were based have been called into question in recent literature (Harbarth, et. [NAME]. [NAME]; [NAME], et. [NAME]. [NAME] Poster 2005; [NAME], et al. CID 6/1/08; [NAME], et. [NAME]. CID 6/1/08). Due to the controversy in care and transmission prevention of drug-resistant organisms (i.e., MRSA, VRE, ESBL-producing enterics), UCSF will continue to utilize Standard Precautions to treat patients with drug-resistant organisms. However, limited active surveillance testing may be informative to confirm assumptions made upon the evidence of clinical cultures (please refer to [NAME] Annual Pathogens Report 2007).
 | 2009-04-01 00:00:00 | 1.Assign responsibility for oversight and coordination of the development, testing and implementation of NPSG.07.03.01 | Met (assumed) | Oversight and coordination will be assumed by [NAME] with ID oversight; ICC will direct [NAME] activities
 | 7/1/2009 (workplan) 1/1/2010: full implementation | 2. An implementation workplan is in place that identified adequate resources, assigned accountabilities and a timeline for full implementation as of Jan 1, 2010. | Pending | Not yet developed | Workplan for limited active surveillance cultures may become part of the ICC responsibility during FY09 | Limited active surveillance culturing may be undertaken to confirm assumptions drawn from clinical cultures.
 | 2009-10-01 00:00:00 | 3. Pilot testing in at least one clinical unit is under way | Pending | Limited testing has been discussed for at least 3 years, and rejected due to costs.
 | 2010-01-01 00:00:00 | 4.  Elements of performance in NPSG.07.03.01 are fully implemented across the hospital. | Pending | Not yet developed
 | 2010-01-01 00:00:00 | 5.  Conduct periodic risk assessments for multidrug-resistant organism acquisition and transmission. (See also IC.01.03.01, EPs 1-5) | Ongoing | Annual Risk Assessment and Plan contains this element.  Please also refer to the Annual Pathogens Report 2007 and going forward (reported in July of each calendar year).
 | 2010-01-01 00:00:00 | 6.  Based on the results of the risk assessment, the hospital educates staff and licensed independent practitioners about health care–associated infections, multidrug-resistant organisms, and prevention strategies at hire and annually thereafter. Note: The education provided recognizes the diverse roles of staff and licensed independent practitioners and is consistent with their roles within the hospital. (See also HR.01.05.03, EP 4) | Ongoing | Annual Risk Assessment and Plan contains this element.  Please also refer to the Annual Pathogens Report 2007 and going forward (reported in July of each calendar year).
 | 2010-01-01 00:00:00 | 7.  The hospital educates patients, and their families as needed, who are infected or colonized with a multidrug-resistant organism about health care–associated infection strategies. | Not met | Educational materials were developed in 2006; however, landscape in patient rooms has not been identified to post the educational materials. | 1.  Develop plan with COO, in-and out-patient units for posting educational materials.  2. Train staff to use educational materials with patients & families.
 | 2010-01-01 00:00:00 | 8.  The hospital implements a surveillance program for multidrug-resistant organisms based on the risk assessment. | Not met: controversial element of perform. | Surveillance program is not recommended by recent literature (see above). Surveillance program is not deemed cost- or outcome-advantageous to populations served at UCSF | Converse with TJC, other UC IC departments regarding recent literature.
 | 2010-01-01 00:00:00 | 9.  The hospital measures and monitors multidrug-resistant organism prevention processes and outcomes including the following: -Multidrug-resistant organism infection rates using evidence-based metrics -Compliance with evidence-based guidelines or best practices -Evaluation of the education program provided to staff and licensed independent practitioners | Not met/controversial element of perform. | Evidence-based metrics for multi-drug-resistant organisms have not been established.  However, UCSF has been monitoring MRSA and VRE recovered from clinical cultures for many years (refer to Annual Pathogens Report 2007).  Evaluation of compliance with hand hygiene, room cleaning, appropriate precautions is monitored and reported to the ICC regularly. | Safety Officer initiated a process to accomplish and monitor equipment cleaning.  This process has stalled, and must be re-started.
 | 2010-01-01 00:00:00 | 10.  The hospital provides multidrug-resistant organism surveillance data to key stakeholders, including leaders, licensed independent practitioners, nursing staff, and other clinicians. | Not met | Annual Pathogens Report is presented to the ICC. | Present Annual Pathogens Report to QIEC and EMB.
 | 2010-01-01 00:00:00 | 11.  As of January 1, 2010, the hospital implements policies and practices aimed at reducing the risk of transmitting multidrug-resistant organisms that meet regulatory requirements and are aligned with evidence-based standards (for example, the Centers for Disease Control and Prevention (CDC) and/or professional organization guidelines). | Met as of August 13, 2008 | Appropriate policies and practices (refer to [NAME], sec 1.1, Standard and Transmission Based Precautions, sec. 1.2, [NAME]) are in place.  Hand hygiene and precautions monitoring ongoing. | Monitor legislative activity for additional requirements. | SB 158 and SB 1058 are active as of this writing, August 13, 2008.  Both require active surveillance culturing for MRSA. Refer to [NAME] summary of the two bills compared to current law (previously SB 739, enacted September 2006).
 | 2010-01-01 00:00:00 | 12.  When indicated by the risk assessment, the hospital implements a laboratory-based alert system that identifies new patients with multidrug-resistant organisms. The alert system may be either manual or electronic or a combination of both of these methods. Note: The alert system may use telephones, faxes, pagers, automated and secure electronic alerts, or a combination of these methods. | Not met | There is no existing labarotory-based alert system for drug-resistant organisms. | Refer to IDMP, then ICC for discussion
 | 2010-01-01 00:00:00 | 13.  When indicated by the risk assessment, the hospital implements an alert system that identifies readmitted or transferred multidrug-resistant organism-positive patients. Note: The alert system information may exist in a separate electronic database or may be integrated into the admission system. The alert system may be either manual or electronic or a combination of both. | Not met | This system does not exist, as UCSF does not isolate patients with drug-resistant organisms. | For discussion with IDMP and ICC.
07.04.01 |  | Implement best practices or evidence-based guidelines to prevent central line–associated bloodstream infections.Note 1: This requirement covers short-and long-term central venous catheters and peripherally inserted central catheter (PICC) lines.Note 2: This requirement has a one-year phase-in period that includes defined expectations for planning, development, and testing(“milestones”) at three, six, and nine months in 2009, with the expectation of full implementation by January 1, 2010. | Partially met (critical care areas) | 1.  Critical care units (neonates, peds, adults) have implemented the CLIP form to document evidence-based practices for line insertion by physicians and NPs.  Post-education, approaching 100% use for all lines placed in critical care areas.  2.  PICC line insertion documentation has not yet aligned with the CLIP form.  3.  CLIP form is available for all CL insertions, irrespective of location, to areas where UCARE is live.  4.  Anticipate CA DHS to require reporting of CL insertion compliance measures in all locations as early as 2009. | 1.  [NAME] and PICC nurses are determining how to document PICC-required and NHSN-required elements efficiently.  2.  [NAME] prepared to enter CLIP data into NHSN database when that module is available.
 | 2009-04-01 00:00:00 | 1.  The hospital’s leadership has assigned responsibility for oversight and coordination of the development, testing, and implementation of NPSG.07.04.01. | Met | [NAME] has led initial efforts, and has been requested to lead ongoing efforts to reduce CRBSI.
 | 2009-07-01 00:00:00 | 2.  An implementation work plan is in place that identifies adequate resources, assigned accountabilities, and a time line for full implementation of NPSG.07.04.01 by January 1, 2010. | Not Met | [NAME] is preparing the workplan for UCSF Med Ctr & CH for review by senior leadership. | Workplan draft 1 to be completed and sent to ID MDs, MC and CH representatives by August 15, to senior leadership by August 29.
 | 2009-10-01 00:00:00 | 3.  Pilot testing in at least one clinical unit is under way for the requirements in NPSG.07.04.01. | Met | 3+ years of work in CRBSI reduction has resulted in reduced infection rates (refer to Critical Care and EMB scorecards)
 | 2010-01-01 00:00:00 | 4.  The elements of performance in NPSG.07.04.01 are fully implemented across the hospital. | Not met | Critical care areas are under continuous surveillance and reporting. |  | Barriers to house-wide implementation of CRBSI reduction efforts include defining CRBSI in Heme/Onc patient population.  Discussion of this barrier has been initiated in the Heme/ID workgroup.
 | 2010-01-01 00:00:00 | 5.  The hospital educates health care workers who are involved in these procedures about health care–associated infections, central line–associated bloodstream infections, and the importance of prevention. Education occurs upon hire, annually thereafter, and when involvement in these procedures is added to an individual’s job responsibilities. | Not met | Ongoing education occurs in critical care areas with bedside nursing staff.  When CRBSI is confirmed, the case is thoroughly reviewed by the VAP/BSI committee.  CRBSI prevention measures are included in the nursing Annual Review online education.  However, annual education for providers has not been addressed. | Discuss in CL TF meeting for ongoing provider education.
 | 2010-01-01 00:00:00 | 6.  Prior to insertion of a central venous catheter, the hospital educates patients and, as needed, their families about central line–associated bloodstream infection prevention. | Not met | This has not been addressed. | CL TF and VAP/BSI Committee to develop written patient/family education about CRBSI.  Consider scripting education for providers who place lines.
 | 2010-01-01 00:00:00 | 7.  The hospital implements policies and practices aimed at reducing the risk of central line–associated bloodstream infections that meet regulatory requirements and are aligned with evidence-based standards (for example, the Centers for Disease Control and Prevention (CDC) and/or professional organization guidelines). | Met | Policies for both MC and CH have been revised or are undergoing revision to align with CDC recommendations.
 | 2010-01-01 00:00:00 | 8.  The hospital conducts periodic risk assessments for surgical site infections, measures central line–associated bloodstream infection rates, monitors compliance with best practices or evidence-based guidelines, and evaluates the effectiveness of prevention efforts.
 | 2010-01-01 00:00:00 | 9.  The hospital provides central line–associated bloodstream infections rate data and prevention outcome measures to key stakeholders including leaders, licensed independent practitioners, nursing staff, and other clinicians. | Met (crtical care) Not Met (acute care) | CRBSI data provided to all critical care units for posting, and is reported through the VAP/BSI  Pt. Safety  Infection Control, Quality Improvement Executive Committees, and to the Executive Medical Board. | A CRBSI reduction initiative is planned for fall 2009 to include acute care units. | Barriers to house-wide implementation of CRBSI reduction efforts include defining CRBSI in Heme/Onc patient population.  Discussion of this barrier has been initiated in the Heme/ID workgroup.
 | 2010-01-01 00:00:00 | 10.  Use a catheter checklist and a standardized protocol for central venous catheter insertion. | Met | CLIP forms were implemented in paper format in 2006. CA law requires reporting of insertion measures as of July 1, 2008.  An electronic CLIP form has been developed and is now the  procedure note for documenting CL insertions in all areas with access to [NAME].  PICC lines are not routinely documented using the CLIP form as of this writing. | 1.  Use of the CLIP form for PICC insertions will be discussed at the 8/18/08 meeting of the CL TF.  PICC nurses have been included in discussions. 2. Analysis of the CLIP forms show that some providers are completing the CLIP form and pasting it into a regular procedure note, making the CLIP form un-searchable in UCARE.  1:1 feedback to those providers is underway.
 | 2010-01-01 00:00:00 | 11.  [NAME] hand hygiene prior to catheter insertion or manipulation. | Met | Analysis of the CLIP forms both before [NAME] implementation and after indicate a high compliance rate (approaching 100%) of HH prior to insertion of CLs. |  | Self-reports and observations confirm a high rate of HH compliance prior to CL insertion.
 | 2010-01-01 00:00:00 | 12.  For adult patients, do not insert catheters into the femoral vein unless other sites are unavailable. | Met | Educational materials include the risks associated with femoral lines.  Infected femoral lines are reviewed with the inserter to determine reasons for using that site. |  | Reasons for femoral site use have been sound.
 | 2010-01-01 00:00:00 | 13. Use a standardized supply cart or kit that is all inclusive for the insertion of central venous catheters. | Not met | Carts were evaluated prior to 2005, then again in 2006.  Losses associated with cart use and lack of storage locations were cited as primary reasons to refrain from implementing a CL Insertion Cart | To be reviewed at VAP/BSI committees in 2008.
 | 2010-01-01 00:00:00 | 14. Use a standardized protocol for maximum sterile barrier precautions during central venous catheter insertion. | Met | Central line insertion kits contain the correct (large) drapes for use while inserting CLs.  Educational materials address reasons and methods for using maximal sterile barrier precautions (full sterile dress, wide draping).  Individual elements of maximum sterile barriers are recorded and attested to on the CLIP form.
 | 2010-01-01 00:00:00 | 15. Use a chlorhexidine-based antiseptic for skin preparation during central venous catheter insertion in patients over two months of age, unless contraindicated. | Met | CHG has been used for CL insertion preparation since 2007 at UCSF MC&CH.  CHG is the skin prep included in the CL insertion kits. PVP idodine is available for CHG-sensitive patients.
 | 2010-01-01 00:00:00 | 16.  Use a standardized protocol to disinfect catheter hubs and injection ports before accessing the ports. | Partially met (CH) | CH implemented a product, policy, and practice improvement (culture change) in April, 2008. | A similar initiative is scheduled for implementation in fall 2008 for adult areas.
 | 2010-01-01 00:00:00 | 17. Evaluate all central venous catheters routinely and remove nonessential catheters. | Met | CA reporting requirements include this element.  Necessity of the line is assessed and recorded by providers and nurses.
07.05.01 |  | Implement best practices for preventing surgical site infections.Note: This requirement has a one-year phase-in period that includes defined expectations for planning, development, and testing(“milestones”) at three, six, and nine months in 2009, with the expectation of full implementation by January 1, 2010.
 | 2009-04-01 00:00:00 | 1. The hospital’s leadership has assigned responsibility for oversight and coordination of the development, testing, and implementation of NPSG.07.05.01. | Met | [NAME] has reviewed and provides ongoing surveillance for several surgical procedures.  Please see monthly ICC FY08 scorecards for most recent data (as of this writing), and the annual HEIC Risk Assessment and Plan. |  | Areas of high risk are identified in the annual HEIC Risk Assessment and Plan.
 | 2009-07-01 00:00:00 | 2.  An implementation work plan is in place that identifies adequate resources, assigned accountabilities, and a time line for full implementation of NPSG.07.05.01 by January 1, 2010. | Met | This is an ongoing effort by [NAME]. |  | [NAME] to annual HEIC Risk Assessment and Plan.
 | 2010-10-01 00:00:00 | 3. Pilot testing in at least one clinical unit is under way, for the requirements in NPSG.07.05.01. | Met | ibid.
 | 2010-01-01 00:00:00 | 4.  Tthe elements of performance in NPSG.07.05.01 are fully implemented across the hospital. | Met | ibid.
 | 2010-01-01 00:00:00 | 5.  The hospital educates health care workers involved in surgical procedures about health care associated infections, surgical site infections, and the importance of prevention. Education occurs upon hire, annually thereafter, and when involvement in surgical procedures is added to an individual’s job responsibilities. | Met | NEO, RN Annual Review and Perioperative training include SSI prevention strategies, and the Perioperative ICP continues that education through case observations and 1:1 feedback to HCW.
 | 2010-01-01 00:00:00 | 6.  As of January 1, 2010, prior to all surgical procedures, the hospital educates patients, and their families as needed, who are undergoing a surgical procedure about surgical site infection prevention. | ? | Prepare provides patients with instruction on skin bathing with [NAME] prior to surgery, unless contraindicated by surgeon request. A supply of [NAME] is provided to the patient. Most of the education involving wound care is provided by the surgery team prior to patient discharge.
 | 2010-01-01 00:00:00 | 7.  The hospital implements policies and practices aimed at reducing the risk of surgical site infections that meet regulatory requirements and are aligned with evidence-based standards (for example, the Centers for Disease Control and Prevention (CDC) and/or professional organization guidelines). (See also UP.01.03.01, EP 5) | Met | Refer to standardized order sets, individual service order sets, AOS, minutes from service-specific meetings.
 | 2010-01-01 00:00:00 | 8.  The hospital conducts periodic risk assessments for surgical site infections, selects surgical site infection measures using best practices or evidence-based guidelines, monitors compliance with best practices or evidence-based guidelines, and evaluates the effectiveness of prevention efforts. | Met | Ongoing review of microbiology reports, surgery schedule and readmissions provide data stream for analysis of services for periodic or ongoing survieillance. ID service provides feedback to [NAME] for areas where potential increase in SSI are noted.  Providers and QI notify [NAME] when potential increase in SSI are noted.
 | 2010-01-01 00:00:00 | 9. Measurement strategies follow evidence-based guidelines, and surgical site infection rates are measured for the first 30 days following procedures that do not involve inserting implantable devices and for the first year following procedures involving implantable devices. | Met | [NAME] to IC Policy Manual for definitions followed for SSI.
 | 2010-01-01 00:00:00 | 10.  The hospital provides surgical site infection rate data and prevention outcome measures to key stakeholders, including leaders, licensed independent practitioners, nursing staff, and other clinicians. | Met | SSI data is provided to services, and is reported to Infection Control, Quality Improvement Executive Committees, and Executive Medical Board, as well as patient safety committees.
 | 2010-01-01 00:00:00 | 11.  Antimicrobial agents for prophylaxis used for a particular procedure or disease are administered according to evidence-based standards and guidelines for best practices.-Administer intravenous antimicrobial prophylaxis within one hour before incision (two hours are allowed for the administration ofvancomycin and fluoroquinolones).-Discontinue the prophylactic antimicrobial agent within 24 hours after surgery (within 48 hours is allowable for cardiothoracicprocedures).Footnote: See Joint Commission core measures at http://www.jointcommission.org/PerformanceMeasurement. | Met | [NAME] to AOS, service-specific order sets.
 | 2010-01-01 00:00:00 | 12.   When hair removal is necessary, the hospital uses clippers or depilatories. Note: Shaving is an inappropriate hair removal method. | Met | [NAME] to [NAME] databases for confirmation of this element.  Razors removed from ORs in 2006, and presence is monitored by OR staff and [NAME].