Will CMS survey enforce OSHA regs?

Closing gap between employee health, patient safety

As the lines blur between patient safety and worker safety, employee health professionals can expect much more scrutiny from regulators who traditionally focused on patient care.

A new draft survey tool from the Center for Medicare & Medicaid Services (CMS) sounds a bit like an inspection checklist from the U.S. Occupational Safety and Health Administration. Is your bloodborne pathogen program up to date? Are you fit-testing at-risk employees every year? Did you document offering the hepatitis B vaccine?

Those are just a few worker-related questions on the new survey tool, which is in its final stages of pilot-testing. The final tool is expected in October.

"The government's catching on that there's a connection between employee safety and patient safety," says Bill Buchta, MD, MPH, medical director of the Occupational Health Service at the Mayo Clinic in Rochester, MN. "But it just seems odd that you have Medicare and Medicaid, where the primary goal is patient safety and getting the best value for your dollar, [asking about] providing hepatitis B vaccine."

In most cases, CMS isn't actually proposing to cite hospitals for worker safety issues. The survey tool contains items that are subject to citation (such as using single-dose vials with more than one patient) and those that aren't subject to citation (such as failure to empty sharps containers). But the tool is also intended for self-assessment by hospitals, says Daniel Schwartz, MD, MBA, chief medical officer of the CMS Survey and Certification Group in Baltimore, MD. "We felt it was important to include those questions that weren't in the standards but that we felt were very important for basic infection control and to prevent the transmission of infections in hospitals," he says.

OSHA worked with CMS

The greater CMS focus on worker safety is no accident. OSHA has been working with CMS to build awareness around the safety culture and work environment, says Dionne Williams, MPH, senior industrial hygienist and a specialist in bloodborne pathogen exposure.

"We're happy to know they're incorporating worker safety in their survey," she says. "Those are the collaborations we're doing behind the scenes to get others involved in fighting the fight for worker safety. "It's an effort to get people thinking that patient safety and worker safety shouldn't be separate. "It needs to be considered all a part of how you're going to improve infection control in the health care setting."

CMS has authority and precedence for expecting hospitals to protect both patients and personnel from infectious diseases. The Conditions of Practice (CoPs) include the stipulation: "The infection control officer or officers must develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel."

CMS also expects hospitals to follow universally accepted guidelines, notes Karen Hoffmann, RN, MS, CIC, FSHEA, infection preventionist with the CMS Survey and Certification Group. "[The provisions of the Bloodborne Pathogen Standard] have been in place since 1991, so that's not beyond minimal standards," she says.

The survey tool includes a catchall requirement for the hospital to demonstrate "general infection control policies and procedures that are based on nationally recognized guidelines and applicable state and federal law." As with other CoPs, failing to do so can result in a citation, the need for a plan of correction — and potential impact on reimbursement.

EH boost from survey items

Whether CMS cites or not on certain items, the inclusion of worker safety on a survey tool could have a significant impact on employee health. Among other infection control items, the tool asks if hospitals:

• provide job-specific training in infection control, including bloodborne pathogen training for those employees with the potential for exposure.

• address sharps injuries and follow up on bloodborne pathogen exposures and TB conversions.

• replace sharps containers when the fill line is reached.

• have a respiratory protection program and annual fit-testing for appropriate personnel.

• have non-punitive work exclusion programs when employees are ill.

• provide hepatitis B vaccine to those with the potential for exposure, offer influenza vaccine and screen appropriate personnel for TB.

At Tampa (FL) General Hospital, JoAnn Shea, MSN, ARNP, director of employee health and wellness, plans to go over each employee-related item with a task force. "We're going to address each of those elements and how we comply," she says.

She anticipates putting the appropriate policies and other information in an easily accessible binder. For example, nurses in the employee health clinic must clear employees for work if they've been absent for three days or more due to illness.

At the Marshfield (WI) Clinic, Bruce Cunha, RN, MS, COHN-S, manager of employee health and safety, asks managers to conduct monthly safety checks in their departments. They observe employees to make sure they're performing hand hygiene, and they peer into sharps containers to make sure safety features have been activated.

Bottom line: Hospitals should already be complying with the items on the CMS infection control assessment, he says. "If you're doing what you should be doing as a health care facility, you've got most of these programs in place," he says.

Be aware of CMS, OSHA differences

It is also interesting to note some things that are missing in the CMS survey tool. An earlier version specifically suggested talking to an employee health professional. The current version instructs the surveyor to talk to "the most appropriate staff person(s) for the items of interest."

That change came as the tool was shortened and streamlined, and wasn't intended to de-emphasize anyone's involvement, says Hoffmann.

The CMS tool does not completely mirror OSHA's Bloodborne Pathogen Standard, notes Pamela Dembski Hart, CHSP, BS, MT (ASCP), principal with Healthcare Accreditation Resources in Boston. For example, it states, "The hospital infection control system trains healthcare personnel that are in contact with bloodborne pathogens on the bloodborne pathogen standards upon hire and when problems are identified."

OSHA requires bloodborne pathogen training upon hire and at least annually, and "when changes such as modification of tasks or procedures or institution of new tasks or procedures affect the employee's occupational exposure."

The assessment tool will be helpful, but won't ensure compliance with OSHA regulations, she notes. "There's definitely overlap with OSHA [in the CMS survey tool]," says Hart. "I think that's great as long as the hospital understands that CMS's goal is not to address OSHA standards in their entirety."

Interestingly, the CMS tool mentions influenza immunization and hepatitis B vaccination, but not MMR, Tdap (pertussis) and varicella. This year, there has been a pertussis outbreak in Washington state and a measles outbreak in Indiana.

CMS may still be revising the tool, notes Schwartz. "We've invited comments from a wide range of organizations. We'll take into consideration any feedback we get," he says.

Beyond the details of the tool, the inclusion of worker safety raises the profile of employee health. And that has been welcomed by employee health professionals.

"CMS has the potential for making change in hospitals," says Cunha.

The Joint Commission accrediting body is likely to follow the CMS lead and focus on the same areas, says Shea. And that means employee health will become a greater priority for hospital administration, she says.

"I don't think we always get acknowledged for what we do to protect the hospital from infections," she says. "Employee health works behind the scenes to make sure our health care workers practice safely, don't have infectious diseases and are treated for exposures."