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– Don’t make so lofty you cannot attain them!

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

• Include what you’re 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:

– IP’s education file – what IP training have you had?

• CIC – good for 5 years, demonstrates professionalism

– IP’s 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 patient’s 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 don’t 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 SIR…run your rates less frequently to allow your denominator to be larger

• 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 IP’s 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.

Questions?