What’s New in the Patient Safety World

February 2015

CMS Infection Control Audit



Since we’ve touched a lot this month on infection control, it is worth noting several new items pertinent to infection control in 2015.


First, CMS (Centers for Medicare & Medicaid Services) has adopted a new Hospital Infection Control Worksheet that will be used during hospital surveys. It has sections on the qualifications of the infection control officer, hospital leadership, infection control programs and indicators used, MDRO’s, antibiotic stewardship, hand hygiene, employee training, employee health, vaccinations, insulin pen safety, vial safety, sharps safety, PPE and precautions, lots of environmental services issues, sterile processing and reprocessing issues, a variety of indwelling catheter issues and respiratory therapy issues, isolation procedures, surgery, spinal injection procedures, point of care devices and others. It’s 49 pages long! Be prepared if you get surveyed!


Second, Joint Commission has announced a new Infection Prevention and HAI Portal. It basically provides you access to all materials pertinent to infection prevention and healthcare-associated infections in one place. It has outstanding tools and links to both Joint Commission resources (individual HAI’s, antibiotic stewardship, hand hygiene, etc.) and external resources like SHEA’s “A Compendium of Strategies to Prevent Healthcare-associated Infections in Acute care Hospitals: 2014 Updates” (SHEA 2014), the Surviving Sepsis Campaign, and many others.


And lastly the New York State Department of Health (NYSDOH 2014) list of locations for reporting CLABSI indicators has been expanded to include:

  1. Medical wards
  2. Surgical wards
  3. Medical-surgical wards
  4. Step-down units

This is to become more consistent with CMS’s Hospital Inpatient Prospective Payment Systems (IPPS) expansion to medical, surgical, and medical-surgical wards effective January 2015.







CMS (Centers for Medicare & Medicaid Services). Hospital Infection Control Worksheet.




The Joint Commission. The Infection Prevention and HAI Portal.




SHEA (The Society for Healthcare Epidemiology of America). A Compendium of Strategies to Prevent Healthcare-associated Infections in Acute care Hospitals: 2014 Updates. Infection Control and Hospital Epidemiology 2014; 35(S2), September 2014



Society of Critical Care Medicine. Surviving Sepsis Campaign.




New York State Department of Health (NYSDOH). Proposed change to 2015 New York State hospital-acquired infection reporting requirements. September 5, 2014






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