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2022 MIPS Improvement Activity IA_ERP_4: Implementation of a Personal Protective Equipment (PPE) Plan

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Activity Description

Implement a plan to acquire, store, maintain, and replenish supplies of personal protective equipment (PPE) for all clinicians or other staff who are in physical proximity to patients.

In accordance with guidance from the Centers for Disease Control and Prevention (CDC) the PPE plan should address:

  • Conventional capacity: PPE controls that should be implemented in general infection prevention and control plans in healthcare settings, including training in proper PPE use.
  • Contingency capacity: actions that may be used temporarily during periods of expected PPE shortages.
  • Crisis capacity: strategies that may need to be considered during periods of known PPE shortages.

The PPE plan should address all of the following types of PPE:

  • Standard precautions (e.g., hand hygiene, prevention of needle-stick or sharps injuries, safe waste management, cleaning and disinfection of the environment)
  • Eye protection
  • Gowns (including coveralls or aprons)
  • Gloves
  • Facemasks
  • Respirators (including N95 respirators)
Activity ID Activity Weighting Sub-Category Name
IA_ERP_4 Medium Emergency Response & Preparedness

Objective

Ensure the safety of patients and staff by maintaining a sufficient supply of personally protective equipment (PPE) for all clinicians and other health workers.

Validation

Documentation of a PPE plan that describes PPE controls and/or a control plan. Include all of the following elements:

  1. Plans for conventional, contingency and crisis capacity situations; AND
  2. Documentation of training – (e.g., curriculum, materials that will be conducted for staff in the use of PPE); AND
  3. Documentation of procurement or existing inventory – This should include all of the following types of PPE:
  • Standard precautions (e.g., hand hygiene, prevention of needle-stick or sharps injuries, safe waste management, cleaning and disinfection of the environment)
  • Eye protection
  • Gowns (including coveralls or aprons)
  • Gloves
  • Facemasks
  • Respirators (including N95 respirators)