Developing an Infection Prevention Program

Mary Ellen Scales

Jacob Smith

Sarah Haessler

How does one know where to start when tasked with creating a new infection prevention (IP) program, assessing an existing program for improvement, or developing a current program into a larger one? This chapter will describe ways to assess the activities of an existing program and determine the resources necessary for right-sizing or creating a program. The approach to all these tasks follows the same general outline: understand and articulate the mission of the IP program and the necessary infrastructure for success, determine what resources are needed to support the program, calculate the costs and benefits of this infrastructure in order to create a business case, and engage the organization’s stakeholders to support the program.

UNDERSTANDING AND CREATING A MISSION AND VISION FOR THE INFECTION PREVENTION PROGRAM

A mission statement is the articulation of fundamental ideas that drive the IP program. It succinctly describes who and what constitutes the program, the goals of the program, and the strategy for achieving those goals.¹ A mission statement should align with the population served, the type of care provided, the healthcare setting, and the ability for the program to prevent infections in that setting. Standard IP goals include protecting the patient, protecting healthcare personnel (HCP) and visitors, meeting regulatory mandates and accreditation standards, and containing costs.² As described by the World Health Organization (WHO),³ the overall vision for IP nationally is best described as “Healthcare without avoidable Infection.” An example of a typical IP mission statement is as follows: “The IP program is a group of experts in IP and control and antimicrobial stewardship. Our mission is to promote safe care by preventing transmission of infectious agents among patients, HCP, and visitors. This will be achieved by ongoing surveillance, educational activities and evidence-based modifications of services based on regulatory standards, scientific studies, and guidelines in a cost effective manner.” Time spent developing a mission statement for the program will pay dividends beyond the initial investment because this activity sets the priorities of the program and enables smooth communication with stakeholders by providing clearly expressed values, goals, and a pathway to reach them. When tasked with creating a new IP program or assessing an existing program, start by creating a mission statement that outlines the values, functions, and goals in order to lay a strong foundation for the program.

NECESSARY INFRASTRUCTURE FOR AN IP PROGRAM

Core Activities of an IP Program

The core activities of any IP program include healthcareassociated infection (HAI) surveillance, meeting accreditation requirements and public reporting, acute event response, performance improvement, and education and training.² When creating a new program or assessing an existing program, priorities should be grounded in these core activities in order to ensure that the basic functions and regulatory requirements for IP are met.

Authority Statement

An authority statement is a document that gives the IP program leaders the authority to enact measures to investigate or apply control measures when needed in order to manage exposures, outbreaks, and other urgent matters. An authority statement is important because it sets expectations between senior administration and the IP program personnel, facilitates a rapid response to infection control matters by removing delays due to bureaucratic or logistic reasons, and gives the program personnel the authority to enact changes to protect patients, staff, and visitors based on their knowledge, experience, and best practices. The creation of an authority statement requires trust between the organization’s administration and the IP program leaders and ideally should be developed jointly. In order to engender trust and set clear expectations regarding the authority delegated to the program, the authority statement could include stipulations that actions taken by IP program leaders will be evidence-based or driven by a committee. An example of an authority statement from Baystate Medical Center is shown in Figure 10-1.

IP Program Reporting Structure

A formal reporting structure provides the hierarchical decision-making and communication pathway for the IP program. There are many reporting models in IP, and the
decision about which to choose can have profound impact on the structure, function, and funding of a program. The traditional reporting structure is one in which the IP program reports to a clinical division or department such as the Infectious Disease Division or Nursing. This reporting structure has the benefit of aligning the IP program with clinicians; however, this often creates a silo that prohibits the program from expansion of ideas and influence in the organization. This type of reporting structure categorizes IP along with direct clinical services and not with other integral support services in the organization such as engineering or environmental services. Examples of reporting structures that are more broadly aligned include those in which IP reports to the Risk Management division, the Healthcare Quality division, the Patient Safety division, or the Chief Medical Officer (CMO). These reporting structures demonstrate a broader conceptualization of the role that the IP program plays, categorizes the program as an essential patient safety activity in the organization, and provides greater access for the IP program to operational leaders.

FIGURE 10-1 Authority statement example from Baystate Medical Center, Springfield, MA.

Personnel

The most important part of an IP program’s infrastructure is its personnel. Determining each staff member’s preparation for their role and their ongoing education is essential for the success of the overall program. Background knowledge of microbiology, public health, nursing, or medicine is essential to lay the groundwork for building an individual’s ability to function and succeed in the day-to-day operation of the program.

The core staff members within an IP program are infection control and prevention practitioners, also called “infection preventionists”, who may have a background in nursing, microbiology, or public health. The skills and competencies required to practice IP are outlined by the Association of Professionals in Infection Control and Prevention (APIC).⁴ Within the field of IP, APIC has described several levels of expertise. These progress from “novice” to “proficient” to “expert” and describe the knowledge and characteristics along with professional activities pertaining to each level. A successful IP should have knowledge of and engage in several practice areas including surveillance and epidemiology of infections, education of provider and ancillary staff along with patients and families, collaboration and consultation to build consensus for IP activities, program management and performance improvement, leadership, and implementation science and research.

Membership in a professional organization expands the ability to receive current literature on evidence-based practices, studies of current problems, and solutions in other programs and care settings. Professional organizations provide the opportunity to network with experienced and related institutional peers to gain knowledge and experience.

The optimum number of IP personnel has been examined in the literature over the past several decades. As the areas for which IP is responsible and the demands on IP time change, prior data regarding the number of IPs per hospital bed or patient care areas may no longer apply.⁵ The scope of IP responsibilities may differ between facilities based on size, teaching status, provision of specialty care, and patient population, and thus estimates for the number of personnel generated by these studies may not be a perfect fit for every facility. The Study on the Efficacy of Nosocomial Infection (SENIC) project, published in 1980, was the first to recommend a certain number of IP personnel per hospital bed.⁶ In 2002, O’Boyle recommended a ratio of 0.8-1.0 IP per 100 beds based on their survey study.⁷ This recommendation was based on changes in patient characteristics along with changes in the tasks that IPs perform. Stone et al.⁸ reported a median ratio of 1 IP to 167 hospital beds based on a national survey of current staff levels in an article published in 2009. They note that larger hospitals had a lower ratio than smaller hospitals. In 2018, Bartles et al. reported that an ideal level for their large organization would be 1 IP to 69 beds; however this also includes IP activities in various long-term care and outpatient settings.⁵

A healthcare epidemiologist (HE) is a medical professional with skills and competencies which are outlined by the Society for Healthcare Epidemiology of America (SHEA) in a White Paper.⁹ In most instances, a HE is a physician with specialty training in infectious diseases; however, they may instead be a member of another closely related discipline such as a microbiologist, public health professional, internist, or hospitalist, among others. HEs perform multiple roles and ideally have expertise in seven distinct areas outlined in Table 10-1. The range and scope of these
content areas requires ongoing engagement with healthcare epidemiology colleagues and the medical literature along with professional societies to develop and maintain the requisite skill set.

TABLE 10-1 Healthcare Epidemiologist Roles and Competencies

*Role*	*Areas of knowledge and action*
Epidemiologist	Epidemiology is the study of the distribution of disease in a population. Healthcare epidemiologists explain infections among people exposed to healthcare and compare to appropriate benchmark rates.
Subject matter expert	Infectious diseases, infection prevention, special populations at elevated risk, construction projects, antimicrobial stewardship
Quality and performance improvement leader	Patient safety and infection prevention are closely connected, and tools useful in infection prevention often apply to other areas needing improvement.
Regulatory/public health liaison	Prepare for and participate in accreditation surveys, collect publicly reported healthcare-associated infection rates, and collaborate with public health departments regarding emergency and pandemic preparedness and response efforts.
Healthcare administrator	Develop budgets, communicate with administrators, facilitate effective meetings, and lead changes for improved care delivery often through culture change.
Clinician educator	Teaching through example, small group presentations, large group lectures and teaching via electronic means, participating in local and regional collaborations.
Outcome assessment evaluator and researcher	Well thought through interventions and appropriate analysis is required in order to improve care delivery and prevent infections. Often this involves collaborating with other divisions for data analysis support.
From Kaye KS, Anderson DJ, Cook E, et al. Guidance for infection prevention and healthcare epidemiology programs: healthcare epidemiologist skills and competencies. Infect Control Hosp Epidemiol. 2015;36:369-380.

The IP program’s activities may also be supported by data analysts, laboratory technologists, quality improvement specialists, and administrative staff. These roles are becoming ever more important as reporting requirements continue to increase over time. The ability to accurately capture, interpret, and utilize data is an essential skill in order to effectively drive IP activities, develop policies, detect and respond to outbreaks, participate in national and state level reporting of data, and communicate with organizational leaders.

Nonpersonnel Infrastructure

IP programs also require nonpersonnel infrastructure including physical space, computers and data processing capacity, and communications systems, along with allocation of time and monies for the training and continuing education of IP personnel. An IP program should have adequate computers and software to communicate with the laboratory, allowing for the seamless collection of infection-related data for surveillance and outbreak investigation purposes as well as for submission of data to fulfill regulatory requirements. Many facilities elect to utilize electronic surveillance platforms which are proprietary software programs that capture specific data elements from the facility’s various databases such as microbiology, daily census, surgical procedures, and pharmacy to provide automated methods to monitor infections. Electronic surveillance software has been shown to reduce IP personnel time to complete surveillance activities,¹⁰ although the systems are costly and not all organizations have the financial resources to invest in the technology.

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