PIECES: A Robust Approach to Infection Control Insert Your Company Logo

Session Objective At the conclusion of this session, participants will be able to: Identify key components to a robust infection prevention program Assess the organization’s infection control strengths and challenges Develop an infection control plan of action www.courtemanche-assocs.com

PIECES of the Infection Control Puzzle When looking at a very complex and high-risk process such as infection prevention and control, it is helpful to identify all the pieces of the IC puzzle and then put them together in a meaningful, successful IC program. www.courtemanche-assocs.com

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PIECES When working to mitigate infection control concerns, think:

P is for . . . Planning Policy Procedure The infection control plan, and associated policies and procedures set forth the roadmap for a solid ICP program.

I is for . . . Involvement of all constituents Identification of risk Implementation of plan Involvement of constituents throughout the organization – medical staff, clinical and facilities associates, etc. Identification of risk – always come back to risk assessment – during planning, implementing new process, refining existing process or when concerns arise Implementation of the plan – does actual practice follow defined policy and procedure?

E is for . . . Education on IC prevention strategies Staff and Physicians Patients Community Establishment of goals Education of key constituents, both within and outside the organization, is vital to the control of infection in the healthcare setting and greater community. Help staff and physicians to understand the “way” behind the “how” of processes that may seem cumbersome or unnecessary. Establishing IC goals (i.e., flu vaccination rates, hand hygiene compliance, etc.) sets forth targets that all constituents can get engaged in. Help staff to understand how their roles and responsibilities can help achieve those goals.

C is for . . . Collecting information Risk assessment Comprehensive and ongoing Data! Data! Data! Analyze and share findings Continually assess risk – consider physical environment, community health, demographics, populations served, scope of services Collecting data is important – but not enough! Once aggregation and analysis has occurred, consider what’s being monitored. Is it still relevant? Is it time to raise the bar? Do we need to modify monitoring techniques (i.e., hand hygiene observations)?

E is for . . . Engagement of all levels of the organization Leadership Physicians Clinical staff Ancillary and support areas Evaluation – annually and ongoing Here’s that engagement thing again! Truly, infection prevention and control is everyone’s responsibility. Helping all constituents to know how they can contribute to goals, and protect themselves, is key! Evaluation – we all do it once a year as part of our planning process; but consider mechanisms to evaluation IC goals throughout the year, when new processes are implemented or new products selected. Are we on track for meeting established goals? Has something changed that would impact those goals? Make (and document) mid-cycle adjustments.

S is for . . . Scopes! Scopes! Scopes! Sharing Storage, disinfection, transport Sharing Responsibility Data and information Potential risk There’s no greater focus right now than on high-level disinfection processes related to medical devices and equipment – especially scopes. Be sure to review TJC’s BoosterPak on HLD and Sterilization. Sharing responsibility for infection prevention and control is key. The ICP professional can guide, direct, serve as the internal expert and support implementation of the plan, policies and procedures, but all members of the organization must be empowered with knowledge and held accountable to responsibilities.

PIECES When you take each of these PIECES, you will be sure to develop, implement and evaluate components of a successful infection control approach. When planning your organization’s approach, be sure to refer to the IC standards and regulatory requirements to assure compliance. Always consider accreditation and regulatory requirements, national guidelines (i.e., CDC, WHO, AAMI, APIC, AORN), manufacturers’ directions, etc. when developing and reviewing policies and procedures. www.courtemanche-assocs.com

S is for . . . Scopes! Scopes! Scopes! Sharing Storage, disinfection, transport Sharing Responsibility Data and information Potential risk

Where Are We in the Process? What are our infection control strengths? Think about each aspect of PIECES. What are our greatest infection control challenges? Use these questions as a starting point for your risk assessment. www.courtemanche-assocs.com

Plan of Action What steps will we take in each PIECE of the puzzle? List actions and assign responsibility and set a follow up date. Think about creating an incentive program – how can you encourage and reward successful progress? Think about creating a newsletter, bulletin board or staff breakfast to share best practices and success stories. www.courtemanche-assocs.com

What Are Our Goals? List your organization’s infection control goals here Discuss how those goals fit into the actions you have identified through your analysis of strengths and challenges of the PIECES. www.courtemanche-assocs.com

Summary Practical steps for ongoing accreditation & regulatory compliance Focus on risk when examining processes Literature review; best practice Organizational experience Review policy against practice Change policy to align with logical, safe practice www.courtemanche-assocs.com

Strategies Assess risk when: Developing/changing/reviewing practice and policy During annual planning When unsafe conditions or “near misses” are reported www.courtemanche-assocs.com

Strategies Incorporate tracer activity and robust rounding in operations Cross functional teams Leadership and front line staff Activities focused on identified gaps and risks Real-time solutions Ease of reporting www.courtemanche-assocs.com

Engaging Everyone! Making accreditation & regulatory compliance an organizational priority – the foundation for care Providing the “why” behind the “how” Using peer coaching and mentoring techniques Engaging various constituents in tracing and rounding Creating the organizational understanding of the impact on quality and safety www.courtemanche-assocs.com

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Thank You, Please Share the PIECES This presentation is copyrighted by Courtemanche & Associates, 2016. This material may be shared for educational purposes in furtherance of infection control practices, but must be credited to Courtemanche & Associates. Special thanks to Courtemanche & Associates’ Jill Ryan, Chief Executive Officer and Senior Consultant, and Sharon Dills, Senior Consultant, for developing this content. Thank you to the National Association for Healthcare Quality (NAHQ) for their partnership with Courtemanche & Associates to distribute this educational material. www.courtemanche-assocs.com

References The Joint Commission Hospital Executive Briefings, New York, September 7, 2016 The Joint Commission Comprehensive Accreditation Manual for Hospitals, 2016 The Joint Commission Survey Activity Guide The Joint Commission® is a registered trademark of Joint Commission on Accreditation of Healthcare Organizations. Courtemanche & Associates has no affiliation with this entity. www.courtemanche-assocs.com

Thank You for Participating! For questions or more information, please contact us at: info@courtemanche-assocs.com (704) 573-4535 www.courtemanche-assocs.com