SQE_presentation

a requirement of SQE.8.2, ME 2, 5th edition)
• Introduces the concept that the hospital is responsible for
identifying strategies that reduce the risk of exposure to
• US CDC now says mandatory for employment unless documented contraindication (flu, Hep B, MMR) • 35,000 US deaths each year from influenza
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SQE.8.2.1: Background
• A patient safety issue—mandatory should be the new norm. • Ethical/professional obligation for protection of patients/selves • Medical ethicists agree that our obligation to protect patients supersedes individual rights for working; they also agree to only
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Requirement Changes: SQE.8.2.1
• Creates new standard to address staff vaccinations and development of strategies for minimizing patient (and staff) exposure to health care associated infections, (previously
• Identify strategies for reducing the patient’s risk of exposure to infections from unvaccinated staff. • Provide evaluation, counseling, and follow-up of staff exposed to infectious diseases; coordinate with PCI program
who are at high risk for exposure to and transmission of
infections; then implement a staff vaccination and immunization
program. How did you decide what was significant?
• Vaccine costs; availability on multiple days; internal or even external display of compliance data
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Surveyor Tips: SQE.5
• New issues for SQE/HR files—surveyors will ask to see work history, orientation, appraisal, and any health information which is mandatory by your hospital or law • How is confidentiality maintained? Where are files kept, and who has access? We will want to visit those areas now.
• A structured staff program to reduce patient and staff exposures • Policies—document review • Approached within the scope of your local laws and regulations (is it legal or not to mandate?—show documentation)
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Surveyor Tips: SQE.8.2
• Understand there are many new requirements to document. • Formal structure/oversight • Documents in files, or separately • Potential workplace violence—can’t be N/A; be proactive • Any incidents of violence—might be N/A • Second victims—a real issue; example sentinel event case
• Oversight responsibility • Compliance expectations from staff • Compliance expectations from leadership to enforce
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SQE.8.2.1: Implement/Measure
• Government recommendations, data collected? • Approach may be population-based locations (MMR) • Treat contact with child-bearing-age females the same as pregnant women • Approach may be job-related locations (Hep B) • May be seasonal or year-round
independent physicians who want hospital privileges
• Exceptions: true allergies/complications (Guillain-Barré) vs. religious beliefs vs. other beliefs (misconceptions)
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SQE.8.2.1: Background
• May already require Hepatitis B, MMR, among others • Staff compliance is mostly very high with Hepatitis B and MMR. • More organizations are mandating staff vaccinations, and this applies to everyone with patient contact.
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Requirement Changes: SQE.8.2
• Introduces a change in the standard that requires the staff
health and safety program to address the physical and mental health of staff and safe working conditions for staff • New requirements identified as a) through g) of the intent and found in ME 2 • New ME 5 – The hospital provides education, counseling, and follow-up for staff who are second victims of adverse or sentinel events.
Staff Qualifications and Education (SQE) th 6 Edition Changes
Requirement Changes: SQE.5
• Provides language in the intent and MEs to clarify the
required contents of a personnel file and adds several components to be added in the file: documentation of orientation and required health information • Adds a requirement to ME 1 that personnel files be kept confidential
medical staff
• If not legal to require vaccines, consider mandatory respiratory precautions, or remove from clinical care for a defined period
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Hale Waihona Puke SQE.8.2.1: Expectations
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SQE.8.2.1: Implement/Measure
• Reinforce hand hygiene program in conjunction with flu program • Ask staff about fever and other symptoms when reporting to work—at shift changes, handovers, and other times. • Remember that waiting for staff to show symptoms is too late.
patients of infectious diseases from unvaccinated staff