The June edition of TJC Perspectives starts off by discussing the changes to NPSG.7 which take effect January 1, 2018. The first important change is to the applicability of NPSG.07.03.01, where carbepenum-resistant enterobacteraceae (CRE) has been added to the list of MDRO’s that are the focus of this safety goal.
The second important change is actually a loosening of an existing requirement relative to education of staff and LIP’s. The annual requirement has been changed to “periodically” as determined by the organization. Unfortunately, terms like periodically or regularly are actually less clear to accredited organizations than a specified point in time. The term is over used in the standards manual with periodic medication storage area inspections, periodic updates of CLIA policies, periodic evaluation of radiation safety badges, OPPE and the culture of safety survey, etc.
If you set your periodic re-education point at every 10 years you are likely to get an RFI from any surveyor, but if you set it at 4 years, or 5 years you would likely only get an RFI from some surveyors. Keeping track of your re-education schedule is also more difficult. Our advice here is to keep the re-education schedule to every 3 years and every time you change your policy or clinical practice guidelines from MDRO.
The central line safety goal, NPSG.07.04.01 is also changing, again with the same change on periodic versus annual re-education for staff and LIP’s. EP 11 is changed, going back to the mandate to use alcoholic chlorhexidine, unless contraindicated, during central line insertion.
These changes are subtle and should not cause major problems for accredited organizations providing you do your edits to policies, clinical practice guidelines, and central line insertion checklists prior to 1/1/18.
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