Table 3.

Compliance with The Joint Commission’s National Patient Safety Goal 07.04.01^*†‡

Joint Commission National Patient Safety Goal 07.04.01 Element	Survey Question	Compliance N= 57 (%)
1. Educate staff and licensed independent practitioners who are involved in managing central lines about 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.	How often do you assess compliance with the above procedures [describing best- practice central line care]?§	54 (95)
3. Implement policies and practices aimed at reducing the risk of central line–associated bloodstream infections. These policies and practices 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).	Do you have pediatric-specific policies related to central line care?║	38 (67)
4. Conduct periodic risk assessments for central line–associated bloodstream infections, monitor compliance with evidence-based practices, and evaluate the effectiveness of prevention efforts. The risk assessments are conducted in time frames defined by the organization and this infection surveillance activity is organization-wide, not targeted.	How do you assess compliance with the above procedures [describing best- practice central line care]?# How does your agency evaluate the effectiveness of its CLABSI prevention efforts? (explain)**	57 (100)
	Answer: used CLABSI numbers or rates	31 (54)
	Answer: used CLABSI events as learning opportunities	11 (19)
	Answer: used either numbers/rates or events	38 (67)
5. Provide central line–associated bloodstream infection rate data and prevention outcome measures to key stakeholders, including leaders,	What is your agency’s overall CLABSI rate since January 2008?††	33 (58)
licensed independent practitioners, nursing staff, and other clinicians.	What is your agency’s pediatric CLABSI rate since January 2008?	17 (30)
7. Perform hand hygiene prior to catheter insertion or manipulation.	Is proper hand hygiene performed prior to all catheter entries?	57 (100)
12. Use a standardized protocol to disinfect catheter hubs and injection ports before accessing the ports.	Is cap connection site scrubbed with alcohol (15 seconds, and 15 second dry) or chlorhexadine (30 seconds, and 30–60 seconds dry) prior to removal of old cap?	46 (81)
13. Evaluate all central venous catheters routinely and remove nonessential catheters.	Is removal of catheter considered/discussed with medical team?	52 (91)
	Is [catheter] site assessed for clean, dry, and intact at every visit?	57 (100)
Total Number of Home Health Care Agencies Consistent with All Elements
All-or-None Measurement Strategy‡‡		10 (18)
Mean Percentage Consistency with Any Element (Standard Error)		82.8% (11.7)

^*Although the Home Healthcare Survey (Appendix 1) uses the term compliance, neither NPSG.07.04.01, Centers for Disease Control and Prevention guidelines for preventing central line–associated bloodstream infection (CLABSI), nor central line care bundles are mandated for home care agencies.

^†The Joint Commission. 2013 Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oak Brook, IL: Joint Commission Resources, 2012; The Joint Commission. 2013 Comprehensive Accreditation Manual for Long Term Care: The Official Handbook. Oak Brook, IL: Joint Commission Resources, 2012.

^‡The following elements of The Joint Commission’s National Patient Safety Goal 07.04.01 were related to central line insertion for adults only and were not asked about in the survey: C2, C6, C8, C9, C10, and C11.

^§Respondents were “compliant” if they assessed compliance at least annually.

^║On the basis of the foundational principle that “children are not little adults” (Moore P. Children are not small adults. Lancet. Aug 22 1998;352(9128):630), respondents were compliant if they had specific line care policies for pediatric patients.

^#Respondents were compliant if they answered anything other than “Not Assessed.”

^**Respondents were compliant if they mentioned CLABSI rates because significant agreement exists that evaluating the effectiveness of any patient safety program requires measurement of data. (McGoldrick M. Preventing central line-associated bloodstream infections and the Joint Commission’s Home Care National Patient Safety Goals. Home Healthc Nurse. 2009;27(4):220–228; quiz 229–230; Langley GJ, et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance, 2nd ed. San Francisco: Jossey-Bass, 2009). Learning from failures is also a potential method to improve processes (Agency for Healthcare Research and Quality. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Apr 2008. Accessed Jun. 17, 2013. http://www.ahrq.gov/qual/hroadvice/hroadvice.pdf), so these results are presented as well.

^††Given that the respondent was a nursing manager or comparable “key stakeholder” in the home health care agency, respondents were compliant if they knew their agency’s central line–associated bloodstream infection rate. If the rate was unknown during the initial survey, we asked them to investigate the rate and the survey administrator followed up with three e-mails trying to determine the rate. As noted above, we consider it integral for agencies to know pediatric central line–associated bloodstream infection rate data, but this was not a specific Joint Commission requirement, this question was not utilized in the aggregate results.

^‡‡Nolan T, Berwick DM. All-or-none measurement raises the bar on performance. JAMA. 2006 Mar 8;295(10):1168–1170.