Infection Prevention Orientation ManualEllen Williams, RN, BA; Pat Fritz, RN, BC, WCC, NHA; Ann Lovejoy, MBA, M.Ed. Show
Download a printable PDF Version of this section. ObjectivesAt the completion of this section the Infection Preventionist (IP) will:
Number of hours
OverviewInfection Prevention is a key component of system-wide quality assurance and performance improvement activities. Hospitals, long-term care facilities, ambulatory surgery centers, and dialysis facilities are required to assure quality and safety for patients, staff, and visitors. The U.S. Centers for Medicare and Medicaid Services (CMS), state regulators, and accreditation bodies recommend that a Quality Assurance and Performance Improvement (QAPI) program be in place and provide evidence demonstrating continuous improvement. A QAPI program consists of systematic and continuous actions that lead to measurable improvement in healthcare services and the health status of targeted patient/resident groups. A QAPI program has five elements: Element 1: Design and Scope are patient-or-resident focused, ongoing and comprehensive. Key ConceptsInfection Prevention ProgramNationally recognized infection control practices or guidelines, applicable regulations of other federal or state agencies, and standards of accreditation are requirements to set the direction for infection prevention programs. The facility’s program for surveillance, prevention, and investigation of infections and communicable diseases should be conducted in accordance with these existing requirements. Additionally, the facility’s infection prevention program must be integrated into its facility-wide Quality Improvement (QI) or QAPI program.1 Goals of the infection prevention program are to:
Accrediting bodies describe methods for how these goals are met. For example, The Joint Commission, www.jointcommission.org, states a comprehensive infection prevention program has a detailed strategic plan that:
Infection Prevention PlanThe Infection Prevention Plan (IPP) is used to assess risk factors, and assure the detection, prevention, and control of infections among patients/residents, visitors and personnel. The scope of services depends on the patient/resident population, function, and specialized needs of the healthcare facility. Completion of a risk assessment, data gathering, and analysis should always drive the plan. The plan should be a working document, reviewed and revised at least annually. The Infection Prevention Plan sets a clear direction for the facility with goals and objectives and establishes processes to identify and reduce risks of infection for patients/residents, visitors, and healthcare workers. Quality Assurance and Preformance Improvement (QAPI) PlanWhile the IPP is the strategic plan for preventing infection in the facility and community, the QAPI plan is the treatment plan for the facility to make infection prevention and quality improvement happen. The QAPI plan is based on information in the IPP and provides the details of what and how infections will be prevented and processes identified as needing improvement. Data drives the QAPI process. 3 The QAPI plan must outline time-framed and realistic goals and include related performance measures that are responsive to the prioritized risks in the infection prevention plan. Quality improvement projects always begin with a QAPI plan. The team-based actions to complete the QAPI plan include the following steps to prepare, write, and evaluate the implementation of the plan: Step 1: Determine what area(s) of improvement the facility needs to focus on and identify people/disciplines using or affected by the process. It is impossible to fix/improve every problem identified at the same time. To focus infection prevention quality improvement efforts:
Step 2: Manage data for performance improvement. Analyze how the facility is collecting, tracking, analyzing, interpreting, and acting on the data. Determine what data to collect for each focus area, how to obtain the data, the person responsible for obtaining the data, the frequency data is to be collected, and how/when the data is reported. Include the information technology department to facilitate electronic data collection when possible. Identify baselines and set targets for improvement. Step 3: Identify potential barriers related to the problem or process to improve. Appendix A illustrates a Barrier Identification and Mitigation (BIM) Tool4 to help the QAPI team systematically identify and prioritize barriers. Barriers can relate to characteristics of the clinicians, the work environment, the culture within the organization, available resources, and many other factors. After the team understands the underlying reasons for the barrier, develop a plan to mitigate the barrier. Step 4: Write and finalize the specific QAPI plan based on the selected priorities, barrier mitigation, and corrective actions steps the team has developed.
Step 5: As progress is monitored, report results of the QAPI Plan to key stakeholders at specified intervals. Include lessons learned along with other outcomes in the report. Take steps to celebrate successes. Data Collection and UseData-enabled decision-making and improvement activities contribute to the quality of services provided to patients/residents. In addition to being a regulatory requirement, data collection assists the IP in:
Plan Do Study Act (PDSA) Model for ImprovementWhen a problem is identified, a standard approach to address the problem is helpful. The PDSA model for improvement is a process commonly used to analyze a problem, develop solutions, implement improvement and evaluate the results. MethodsInitiate Infection Prevention Program through PlanningThe IPP is a roadmap for how the Infection Prevention Program will work during the year. The plan must be flexible to facilitate alteration in response to unexpected disease processes or environmental issues and yet contain specific, realistic, and measureable goals. The IPP is used to determine quality improvement activities, increase adherence to infection prevention practices, improve patient/resident outcomes, and prevent HAIs. As seen in Figure 1, quality improvement efforts typically involve five steps.6 Steps include:
Figure 1. Steps in the Quality Improvement Process.6 The best way to involve people and their talents appropriately is to develop the plan using a team approach by engaging people in the Infection Prevention Committee. Meaningful, ongoing team activities may include periodic reviews of data, development of tools & processes to facilitate implementation of best practices, and feedback to staff and administration. Multidisciplinary teams increase problem identification and solution development. Utilization of patient/resident and front-line staff expertise and knowledge of the problem can improve interventions and implementation processes. A full evaluation of the IPP should be done annually. The Infection Prevention Committee minimally consists of a physician, front-line nursing staff, quality improvement/risk management staff, and representatives from microbiology, central sterilization, environmental services, pharmacy, and administration. Additional staff members may be asked to provide input or join the committee as issues arise.7, 8 Infection Prevention Program Roles and ResponsibilitiesThe infection prevention program involves many stakeholders, both on and off of the infection prevention committee. Roles and responsibilities for how the regulatory bodies, IP and IP Team work together to create or update a plan are shown in Figure 2. To read the work flow, begin in the upper left corner of the top IP Team role lane. Follow the arrows. Joint actions appear in Figure 2 as action-step boxes that straddles the line between two or more roles. Figure 2. Roles and Responsibilities for Infection Prevention Plan Development. Abbreviations include: IC (Infection Control), IP (Infection Prevention Professional), PDSA (Plan, Do, Study, Act), Plan of Correction (a Corrective Action Plan), QAPI (Quality Assurance and Performance Improvement), QI Process (Quality Improvement). Analyzing Risks and Setting Priorities for ActionIndividuals delivering clinical and care-related services are frequently not on the infection prevention committee. The team and relationships the IP builds in the facility assure individuals will take the risk of infection seriously and facilitate their engagement. Their collaboration and behavior are very important to reduce or eliminate risks of infection. Identifying the risks is not enough to prevent infections. Risks must be analyzed for severity and the actual frequency of occurrence in a facility. This analysis helps the committee prioritize the risks identified during plan development or update. The IP and the committee have a finite amount of time and resources and are more likely to be successful in reducing risks if they focus on a few key items. There are many tools available to help identify and prioritize infection risks. It’s best for the IP to select a tool to help define a prioritization method. Appendix B provides examples of these tools. A team-based review of the priorities by the infection prevention committee is helpful. Documenting the prioritized risks and rationale for selection helps people outside the team accept and spread improvements throughout the facility. The more people engaged with the goals, the better. Designing and Implementing SolutionsOnce a risk is identified and prioritized for action, a quality improvement solution is designed using a quality improvement model. Healthcare facilities can employ various approaches and models to improve quality including: Gap Analysis9; Root Cause Analysis 10, 11; Failure Mode Effect Analysis12; Strength, Weaknesses, Opportunities, Threats Analysis13; Multi-voting14; Goal-Directed Checklists15; Process Control, Charts, Graphs, and Clinical Practice Guidelines16; Six Sigma and Lean Approach17; and the PDSA Performance Improvement Model.18 The PDSA Model for ImprovementThe PDSA model for improvement18 is a four-step method used to implement a guideline or work flow change and process improvement. A team is established based on the risk or problem that needs to be improved. The team should include an administrative person who is able to allocate funds if needed; a front-line staff member who is involved in using the process, and a patient/resident representative when possible. The important elements of the PDSA improvement model are shown in detail in Figure 3. Figure 3: Plan, Do, Study, Act Improvement model. 18 The PDSA Model tests implemented changes. Following the prescribed four steps (1) plan, (2) do, (3) study, and (4) act guides the thinking process. Each step helps assure good results, breaking down the task into reasonable steps, evaluating the outcome, improving on it, and testing again. PDSA is very similar to the Nursing Process (Appendix E) which includes the five elements of (1) assessment, (2) diagnosis, (3) outcomes/planning, (4) implementation and (5) evaluation. Each element of the Nursing Process corresponds with one or more of the initial questions and steps of the PDSA improvement model in Table 1. Table 1. Elements of the Nursing Process corresponding to the PDSA model for improvement. If the first PDSA attempt doesn’t completely solve the problem, additional improvement “cycles” may be done. After one cycle of all four steps, a new PDSA cycle begins from that point. These repeated uses of PDSA are also called “tests of change.” A schematic of this process of repeating PDSA cycles is shown in Figure 4.19 Repeated use of the PDSA cycle fosters improvement by successive refinements that are documented and enhanced. The IP must keep the following details in mind when using the PDSA model in cycles:
Figure 4. Sequential use of the PDSA model for improvement.19 Reprinted with permission from Associates in Process Improvement. Quality Improvement Measures and ReportingPeriodic review of performance is critical for assessing the effectiveness of quality improvement interventions. Process measures are concerned with activities within a care episode and relate to action steps such as patient safety and clinical procedures that are done consistently. Outcome measures are closely associated with patient/resident outcomes or results. Either kind of measure can be used to evaluate performance. Measures provide a common language with which to evaluate the success of interventions. Process measures include the goal of a 100% rate of adherence to the recommended practice and do not require adjustment for patients’ underlying risk of infection or severity of disease. Loosely, the words “measure” and “indicator” refer to quantitative ratios or comparisons that reflect the status of a process or result of a process. In the 1980s, efforts began to promote public reporting of data by the Health Care Financing Administration (the predecessor of CMS). While public reporting of healthcare data has advanced considerably in depth and scope, it is still an evolving process. CMS posts performance information about cost and quality levels of providers such as hospitals, physicians, home health facilities, nursing homes, dialysis centers, and ambulatory surgery centers. Public reporting helps consumers make informed decisions when choosing a provider and to provide data for value-based purchasing of healthcare services by CMS and other payers. CMS provides healthcare data to the public via their website www.medicare.gov. Additionally, several private organizations report quality data in the public interest. Examples include: Leapfrog, Consumer Reports, UCompareHealthCare, Commonwealth’s Why Not the Best, and Healthgrades. The additional transparency via the availability of information for consumers, has changed the behavior of staff within the healthcare industry. Interviews with hospital staff regarding the public reporting of quality measures in one study revealed common themes.20 Themes include:
The healthcare industry is moving toward greater openness and accountability. A key result of this shift is clinical staff and leaders re-prioritizing healthcare quality improvement as a more important goal. Infection Prevention Measures and ReportingHAI data for hospitals is provided to CMS by the Center for Disease Control and Prevention (CDC) via their electronic HAI tracking system called National Healthcare Safety Network (NHSN).21 See Appendices I and J for a list of indicators currently reported publicly. While reporting is voluntary, Medicare payments are decreased if hospitals participating in the Prospective Payment System (PPS) do not collect and submit the required data. The data from several indicators are also used by CMS to calculate payments in the Value-Based Payments system. For the most current information on CMS public reporting and value-based programs see www.cms.gov and www.qualitynet.org. The CMS based their reporting requirements on a 1995 Society for Healthcare Epidemiology of America (SHEA; www.shea-online.org) position paper describing the criteria for selection of quality indicators.22 The SHEA criteria include: identifying quality indicator events that are clearly defined with numerators and denominators, using indicator variables that are easy to identify and collect, selecting data collection methods that are sensitive enough to capture the data and that can be standardized across all institutions, selecting indicator events that occur frequently enough to provide an adequate sample size, and comparing populations with similar intrinsic risks or providing appropriate risk adjustments. Surveillance of HAIs initially focused on device- and procedure-associated infections because these infections occur among hospitalized patients and are associated with potentially modifiable risk factors. The most widely used definitions for healthcare related infections are the CDC definitions located on the NHSN website, www.cdc.gov/nhsn. The McGreer Criteria are used for long term care facilities and may be found at www.premierinc.com/quality-safety/tools-services/safety/topics/guidelines/downloads/25_itcdefs-91.pdf. These definitions were updated in 2013 and the newer version can be found at: www.ncbi.nlm.nih.gov/pmc/articles/PMC3538836/. Even when standardized NHSN and McGreer definitions are used, the interpretation of HAI definitions can vary between users and different approaches to surveillance applied. These variations in interpretation of available data sources and methods can adversely impact the completeness and comparability of HAI data. There is growing evidence that HAI surveillance methods that use readily accessible automated data for screening are a more resource-efficient approach; however, these information technology applications cannot replace frontline surveillance by trained personnel. In addition, risk adjustment to account for underlying differences between healthcare facilities’ patient populations is essential for meaningful comparisons.23 For the IP, NHSN is the HAI surveillance gold standard because it provides:
The benefits to using NHSN are many, and most facilities utilize the system for the following:
The NHSN system requires facility and individual registration. To enroll a facility, an IP should visit the CDC NHSN website www.cdc.gov/nhsn/enrollment/index.html, click on the link for the facility type, and follow the instructions. When the facility enrollment process is complete, the NHSN facility administrator (person listed on the NHSN enrollment application) will receive an email with instructions for obtaining a digital certificate or an invitation to register for Secure Access Management Services (SAMS). CDC is in the process of initiating the implementation of the SAMS system. More information can be located at www.cdc.gov/nhsn/sams/about-sams.html. CDC provides training for each facility type, NHSN administrator and group roles, each NHSN module, and how to use the analysis feature. Tips for SuccessEstablish a culture of quality by demonstrating to the infection prevention team what infection prevention quality looks like for the organization. Communicate that vision to staff in the facility and to the community. The structure and process for quality improvement should be visible and easily understood by everyone. Buy-in and support at all levels is essential to successfully implement the infection prevention and quality improvement plan. While quality improvement requires an investment of time, staff and fiscal resources, the benefits are improved patient/resident outcomes, increased efficiency, improved healthcare worker safety, improved customer satisfaction and potentially decreased costs. ResourcesHelpful/Related Readings
Helpful Contacts (in WY or US)
Related Websites/Organizations
My Facility/City/County Contacts in this AreaDevelop a list of contacts (include their phone number, email, facility/company, address, and area of expertise). Resources may include sources such as APIC members, other IPs, QIO contacts, State employees. References
AppendicesPlease download the printable PDF Version of this section, linked at the top of the page, to view the following appendices: Appendix A: John’s Hopkins Barrier Identification and Mitigation Tool What is the priority goal of interventions for a risk diagnosis?What is the priority goal of interventions for a risk diagnosis? (For "risk" nursing diagnoses, the priority goal is to prevent the problem from occurring by implementing interventions that reduce or eliminate risk factors or by collecting additional data. )
What are goals in nursing diagnosis?Goals are broad statements of purpose that describe the overall aim of care. Goals can be short- or long-term. The time frame for short- and long-term goals is dependent on the setting in which the care is provided.
Which is the primary goal of the assessment phase of the nursing process?The assessment phase of the nursing process involves gathering information about the patient which is used to guide planning care, setting goals for recovery, and evaluating patient progress. Nurses can obtain information about the patient by implementing the following objectives.
Which type of nursing diagnosis has a goal to increase well being and enhance specific health behaviors?A health promotion-wellness nursing diagnosis is “a clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential.” These responses are expressed by the patient's readiness to enhance specific health behaviors.
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