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  • There are 13 questions on the exam related to

    Management and Communication. Content, related

    to the Infection Prevention Program, addresses:

    Planning Develop, evaluate and revise a mission and vision

    statement with goals, measurable objectives and action

    plans

    Assess needs, recommend equipment, personnel and

    resources

    Participate in cost benefit assessments, efficacy

    studies, evaluations and standardization of products

    Recommend changes in practice based on evidence,

    outcomes and financial implication

    Incorporate business modeling to assign value to the

    prevention of and/or presence of HAIs

  • Communication and Feedback

    Provide infection prevention findings, recommendations

    and reports to appropriate stakeholders

    Facilitate implementation of policies, procedures and

    recommendations

    Communicate effectively with internal and external

    stakeholders

    Collaborate with internal and external stakeholders in the

    identification and review of adverse and sentinel events

    Evaluate and facilitate compliance with accreditation

    standards/regulatory requirements

    Perform and create a personalized development plan

  • Quality/Performance Improvement and Patient Safety

    Participate in quality/performance improvement and

    patient safety activities related to infection prevention

    Develop, monitor, measure and evaluate performance

    indicators to drive quality improvement initiatives and

    activities

    Select and apply appropriate quality/performance

    improvement tools, such as fishbone diagram, Pareto

    charts, flow charts, SWOT (Strenghts-Weaknesses-

    Opportunities-Threats), Gap Analysis

  • KEY CONCEPTS

    1) Successful approaches for preventing and reducing

    HAIs relies on the effective interplay of multiple

    management systems.

    2) A comprehensive, organizational approach is

    essential to manage infection risk and improve

    patient safety.

    3) Infection prevention must be fully integrated into the

    structure, systems, metrics and culture of the

    organization.

    4) An effective IP program encompasses responsibility,

    collaboration, consultation, and a broad vision to

    look at community risks and resources.

  • Corresponding APIC text chapters:(APIC TEXT of INFECTION CONTROL and EPIDEMIOLOGY, 4th edition)

    Ch 1 Infection Prevention and Control Programs

    Ch 2 Competency and Certification of the IP

    Ch 3 Education and Training

    Ch 4 Accrediting and Regulatory Agencies

    Ch 5 Infection Prevention and Behavioral Interventions

    Ch 6 Healthcare Informatics and Information Technology

    Ch 8 Legal Issues

    Ch 9 Staffing

    Ch 16 Quality Concepts

    Ch 17 Performance Measures

    Ch 18 Patient Safety

  • 1985, SENIC (Study of the Efficacy of Nosocomial Infection Control) One ICP (infection control professional):250 beds

    An effective infection control physician

    Program reporting infection rates back to the surgeon and those clinically involved with the infection

    An organized hospital-wide surveillance system

    Current IC Challenges to healthcare include: Decreasing reimbursement

    Increasing emerging infections, resistant organisms, drug costs

    Multiple benchmark systems

    Public reporting of infections

    No regulatory requirements of # of IPs per patient bed

  • The Infection Prevention and Control Program Resources both human and non-human

    Policies include Authority Statements, BBP and TB exposure control plans

    Risk Assessment must be done at least annually

    Include language from your accrediting body (ex. DNV, TJC)

    Include new services, patient populations, etc.

    Plan and evaluations of plan

    Make goals objective and measurable Dont make so lofty you cannot attain them!

    Make sure they fit with your overall facility goals & mission statement!

    Include what youre going to monitor and why

    Include methods of evaluation in your plan

    If goal is not met, keep it on plan for the next year

  • Role of the ICP (IP) Oversight / management of:

    Surveillance

    Specific environmental monitoring

    Continuous quality improvement

    Consultation

    Committee involvement

    Outbreak and isolation management

    Regulatory compliance

    Education

    Promotion of program Includes ability to present business case for program

    (i.e. preparing ROIs [returns on investment] for items related to infection prevention)

  • Competency & Certification of the IP

    Basic infection control courses keep documentation of these!

    CIC (Certification in Infection Control)

    Requirements:

    http://www.cbic.org/certification/candidate-handbook/eligibility-requirements

    People skills not a requirement, but will make your life considerably easier!!

  • The 20 People Skills You Need to Succeed at Work

    Ability to relate to others Strong communication skills Patience with others Ability to trust others Knowing how and when to show empathy Active listening skills Genuine interest in others Flexibility Good judgment Ability to persuade others Negotiation skills Ability to keep an open mind

  • The 20 People Skills You Need to Succeed at Work (cont)

    Knowing your audience

    Honesty

    Awareness of body language

    Proactive problem solving

    Leadership skills

    Good manners

    The ability to be supportive and motivate others

  • Education and Training Many educational opportunities for the IP:

    TSICP, APIC, SHEA, TMF, CMS

    Familiarize yourself with adult education principles so you will be able to teach others

    Learn what works best in your facility and on various units

    Videos, one to one, newsletters, posters, short presentations (great with lunch provided!)

    Your employees need at a minimum:

    Annual OSHA bloodborne pathogen, tuberculosis prevention and control, new employee orientation

  • Accrediting and Regulatory Agencies

    Examples:

    The Joint Commission (TJC)

    Det Norske Veritas (DNV)

    Centers for Medicare and Medicaid Services (CMS)

    Occupational Safety and Health Administration (OSHA)

    State and local health authorities

  • Accrediting and Regulatory Agencies Standards between various agencies similar and most will

    require items such as: IC Risk Assessment

    IC Plan with goals and evaluation

    IP roles / responsibilities / oversight

    Documentation / tracking of infections

    Reporting of infections

    Hand hygiene monitoring and reporting

    Elements of employee health vaccination requirements, communicable illnesses in HCWs and time off requirements, influenza vaccination program (yearly evaluation and goals)

    IC Policies (some may live in other departments!) Cleaning / disinfection including high-level disinfection

    Sterilization including item recall processes

    Emergency Preparedness / Management

    Environment of Care policies (ex. monitoring of negative pressure rooms)

  • Accrediting and Regulatory Agencies

    Surveyors will immediately ask for this information during surveys:

    IPs education file what IP training have you had?

    CIC good for 5 years, demonstrates professionalism

    IPs job description does it cover all the items needed to manage / maintain the overall IP Program?

    CMS requirement Infection Control Officer

    IP Risk Assessment and Plan

  • Quality Concepts FMEA (failure mode and effects analysis)

    Proactive, preventive, identifies potential failures and opportunities for error

    Model for Improvement (Institute for Healthcare Improvement) Setting aims, establishing measures and selecting changes

    PDSA (Plan, Do, Study, Act) small scale testing, followed by refinement and more testing, then roll out on larger scale

    Adverse Event unintended consequence of healthcare that results in a negative patient outcome

    Near-miss Event unplanned event that could have resulted in injury, illness or damage but did not either by chance or timely intervention

    Sentinel Event defined by TJC as any unanticipated event in a healthcare setting resulting in death or serious injury to a patient or patients and is not related to the natural course of the patients illness

    RCA (root cause analysis) used to investigate sentinel events

  • Performance Measures

    Presenting your data:

    Use visuals (histograms, charts) whenever possible

    Use colors in your charts, but dont make them too busy; keep it legible

    Be able to explain any data you have included in the charts or presentation

    NHSN has a variety of tools available to assist you in presenting your data

  • Standardized Infection Ration (SIR)

    Summary measure used to track HAIs at a national, state, or local level over time

    Adjusts for patients of varying risk within each facility

    Compares actual number of HAIs reported with the baseline U.S. experience

    Value > 1.0 = more HAIs seen than predicted

    Value < 1.0 = fewer HAIs seen than predicted

  • SIR: Things to Remember

    SIRs only calculated if number of expected HAIs is >/= 1

    If your denominator (surgeries, line days, etc.) is very small, NHSN may not calculate an SIRrun your rates less frequently to allow your denominator to be larger

    http://www.cdc.gov/nhsn/PDFs/Newsletters/NHSN_NL_OCT_2010SE_final.pdf

    http://www.cdc.gov/nhsn/PDFs/Newsletters/NHSN_NL_OCT_2010SE_final.pdf
  • Putting in all together:

    Which of the following terms refers to patient harm that is the result of treatment by the healthcare system rather than from the health condition of the patient?

    Adverse event

    Dire consequence

    Unanticipated event

    Sentinel event

  • Putting in all together:

    Which of the following terms refers to patient harm that is the result of treatment by the healthcare system rather than from the health condition of the patient?

    Adverse event

    Dire consequence

    Unanticipated event

    Sentinel event

  • Putting in all together:

    TJC standards for infection prevention and control include all of the following except:

    Collaboration within the organization in the implementation of the program

    Effective management of the IP program

    Minimizing risk for development of a HAI through an organization-wide IP program

    Specific staffing requirement of one IP for every 100 beds in the facility

  • Putting in all together:

    TJC standards for infection prevention and control include all of the following except:

    Collaboration within the organization in the implementation of the program

    Effective management of the IP program

    Minimizing risk for development of a HAI through an organization-wide IP program

    Specific staffing requirement of one IP for every 100 beds in the facility

  • Putting in all together:

    The IP has proposed using an electronic surveillance system. Senior leadership now wants to know what the expected ROI (return on investment) will be. What is the IPs next step?

  • Putting in all together:

    Describe the project cost baseline developed from previous department budgets

    Provide a synopsis of the investment and direct and indirect costs, including factors such as capital expenses, depreciation, and inflation

    Project the impact of the surveillance system on hospital net revenue

    Calculate the amount of time needed to pay back the initial costs of the system

  • Putting in all together:

    Describe the project cost baseline developed from previous department budgets

    Provide a synopsis of the investment and direct and indirect costs, including factors such as capital expenses, depreciation, and inflation

    Project the impact of the surveillance system on hospital net revenue

    Calculate the amount of time needed to pay back the initial costs of the system

  • Putting in all together:

    Which of the following milestones indicates that the IP has achieved proficient status according to the APIC Competency Model? After successfully completing his / her CIC

    Upon obtaining a graduate degree in a healthcare-related field

    When continuously employed as an IP for more than 2 years

    After 10 years of experience as the manager of an IP program

  • Putting in all together:

    Which of the following milestones indicates that the IP has achieved proficient status according to the APIC Competency Model? After successfully completing his / her CIC

    Upon obtaining a graduate degree in a healthcare-related field

    When continuously employed as an IP for more than 2 years

    After 10 years of experience as the manager of an IP program

  • References:

    Hoffmann, K. (2001, December 1). Developing an Infection Control Program.

    Infection Control Today.

    http://www.cdc.gov/nhsn/PDFs/Newsletters/NHSN_NL_OCT_2010SE_final.p

    df

    Smith, J. (2013, November 15). The 20 People Skills You Need to Succeed at

    Work. Forbes.

    http://www.cdc.gov/nhsn/PDFs/Newsletters/NHSN_NL_OCT_2010SE_final.pdf
  • Questions?