1. PIECES: A Robust Approach to Infection Control
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2. 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

3. 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.

5. PIECES When working to mitigate infection control concerns, think:

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

7. 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?

8. 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.

9. 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)?

10. 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.

11. 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.

12. 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.

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

14. 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.

15. 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.

16. 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.

17. 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

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

19. 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

20. 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

22. Thank You, Please Share the PIECES
This presentation is copyrighted by Courtemanche & Associates, 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.

23. 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.

24. Thank You for Participating!
For questions or more information,
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