The Joint Commission has developed National Patient Safety Goals (NPSG) involving Infection Prevention that include:

• Prevention of Central Line Associated Bloodstream Infections (CLABSI)• Prevention of Multi-Drug Resistant Organisms (MDRO)

• Prevention of Surgical Site Infection (SSI)

These Joint Commission National Patient Safety Goals have aggressive time lines for completion for specific elements of

performance. Included in these deadlines are staff education . In order for our facilities to be compliant with the Joint Commission, 3 new CBLs have been developed for mandatory staff education.

1. Modules must be completed by December 1, 2009. 2. All modules will need to be completed annually after this initial 2009 rollout completion.3. Nursing Assistants will ONLY complete the MDRO and the SSI modules (They do NOT complete the CLABSI CBL).4. Contract Staff, MD’s, Students, Environmental Services and others are also expected to receive education as it

applies to their practice.5. Infection Control & Prevention will work with Corporate Education to provide periodic unit specific education

compliance reports.6. Estimated time to complete all 3 modules: 20 - 30 minutes.

The CLABSI Prevention CBL should be completed by the following employees: Everyone who either assists with the

central line (CL) in any way, including assisting with putting them in, pushing fluids through or drawing blood from a CL or

doing CL dressing changes. These employees may also include those in Radiology, PACU, OR, Anesthesia and all nursing units.

The SSI Prevention CBL should be completed by the following employees: Everyone who is involved in surgical procedures

or assists in the care of surgical patients preoperatively, intra-operatively and postoperatively.

The MDRO Prevention CBL should be completed by the following employees: Everyone who is involved in patient care.

Deadline: December 1, 2009

For question: Contact Infection Control/ Prevention via On-call pager: 704.356.7050