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WINTER 2017 • VOLUME 10 NUMBER 4

Getting from the starting point to the finish line: Project management skills for IPs

Making the business case: A financial primer for IPs

Talking to the C-suite: How to convert infection prevention words into C-suite language


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Contents

FEATURES

WINTER 2017

ZURAINY ZAIN/SHUTTERSTOCK.COM

Getting from the starting point to the finish line: Project management skills for IPs

54

Making the business case: A financial primer for IPs

61 4 | WINTER 2017 | Prevention

Talking to the C-suite: How to convert infection prevention words into C-suite language

66


VOICE Leadership: The “secret sauce”

6

A leadership mindset

8

7,000 and counting…

10

By Linda Greene, 2017 APIC President By Katrina Crist, APIC CEO By Lita Jo Henman, 2017 CBIC President

DEPARTMENTS Briefs to keep you in-the-know • APIC 2017 Heroes of Infection Prevention, part two • U.S. Antibiotic Awareness Week • CDC funds new efforts for infectious disease threats • ICYMI: APIC MegaSurvey • NEW! Forms & Checklists for Infection Prevention, Volumes 1 & 2 • ABCs of Antibiotics infographic • A AMI update on sterilization of endoscopes • APIC Education Online

12

Meet a CIC: Patty Montgomery

19

APIC Consultant Corner: Being an interim IP A conversation with Christina Wahrmund

Capitol Comments: Certification—the new expectation for IPs By Rich Capparell, Nancy Hailpern and Lisa Tomlinson

22 25

PREVENTION IN ACTION My Bugaboo: Common etiologic agents of pneumonia 

28

From data to decisions: Incidence versus prevalence

32

Focus on long-term care and behavioral health outbreaks: Identify the pathogen!

37

Becoming an APIC Fellow

41

CMS mandates water management programs in healthcare facilities

46

In pursuit of a fair and just culture: An application of key components in infection prevention

50

By Irena Kenneley

By Daniel Bronson-Lowe and Christina Bronson-Lowe

By Steven Schweon By Lisa Caffery

By May Mei-Sheng Riley and Annemarie Flood

By Savanna Stout

28

ERRATUM — FALL 2017 ISSUE Page 72 The article “2017 HICPAC-CDC Guideline for prevention of surgical site infection: What the IP needs to know” in the Fall 2017 issue of Prevention Strategist listed reference #6 incorrectly. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg 2017;152(8):784 -791. doi:10.1001/jamasurg.2017.0904.

46

50 w w w.apic.org | 5


PRESIDENT’S MESSAGE

Leadership: The “secret sauce”

BY LINDA GREENE, RN, MPS, CIC, FAPIC 2017 APIC PRESIDENT

“As I reflect upon leadership, I have been incredibly fortunate to work with a talented and thoughtful APIC Board of Directors who think strategically and are future oriented.”

IT’S HARD TO believe that a year could go by so quickly. As I reflect back on my year as APIC president, I’ve had the opportunity to meet many dedicated, passionate, and inspirational colleagues who have had a significant impact on reducing healthcare-associated infections and improving patient safety. As I think about these individuals and what sets them apart, there seems to be a common theme—leadership. Although there are a number of definitions for leadership, one simple example defines leadership as “the ability to influence others.” Whether it is translating evidence into practice or talking to the C-suite, the infection preventionist (IP) needs strong leadership skills in order to be an effective influencer. We also know that good leadership requires both technical and adaptive skills (sometimes referred to as the “soft skills”). A 2010 study conducted in Michigan by Dr. Sanjay Saint concluded that leadership plays a key role in infection prevention, and that the challenging process of translating the findings of infection prevention research into practice can be eased by leaders who heed the advice and experiences of their colleagues. As APIC members, we have the opportunity to network, engage, and leverage the talent and skills of incredibly capable colleagues and leaders who can offer advice and share their experience. This issue of Prevention Strategist focuses on leadership. You will find articles specifically aimed at developing or enhancing leadership skills such as understanding budgets, project management for the IP, and how IPs should talk to the C-suite. As I reflect upon leadership, I have been incredibly fortunate to work with a talented and thoughtful APIC Board of Directors who think strategically and are future oriented. Over the past year, APIC has continued to be acknowledged and recognized for the pivotal role we play in infection prevention and patient safety. We are particularly proud that APIC was invited to discuss the important role of infection prevention at the President’s Council on Combating Antibiotic Resistant Bacteria. We have also continued to advance and support our international presence—APIC was invited to be part of the World Health Organization’s (WHO) Global Infection Prevention and Control Priorities Network, where we worked with colleagues across the globe to identify the top five infection control priorities in the next five years, and to establish a collaborative framework for the future. One of our important strategic initiatives is to identify, develop, and define what the IP is, and to put in place foundational components to support recruiting and retention. In addition, the APIC board has begun discussion to characterize the desired state of the IP of the future, a process which will involve input from multiple stakeholders and leaders as we move forward. Many of these initiatives will span consecutive years and will need skilled and talented leaders who can continue this important work. With that in mind, I am delighted to hand over the leadership to Janet Haas, the incoming president. Janet is a talented and visionary leader who will serve APIC well in the coming year.

Linda Greene, RN, MPS, CIC, FAPIC

6 | WINTER 2017 | Prevention

Prevention W I N T E R 2 017 • VO L U M E 10 , I S S U E 4

BOARD OF DIRECTORS President Linda Greene, RN, MPS, CIC, FAPIC President-Elect Janet Haas, PhD, RN, CIC, FSHEA, FAPIC Treasurer Sharon Williamson, MT(ASCP)SM, CIC, FAPIC Secretary Linda McKinley, RN, BSN, MPH, CIC, FAPIC Immediate Past President Susan Dolan, RN, MS, CIC, FAPIC

DIRECTORS Dale Bratzler, DO, MPH, MACOI, FIDSA Tania Bubb, PhD, RN, CIC, FAPIC Thomas Button, RN, BSN, NE-BC, CIC, FAPIC Kim Boynton-Delahanty, RN, BSN, PHN, MBA/HCM, CIC, FAPIC Annemarie Flood, RN, BSN, MPH, CIC, FAPIC Irena Kenneley, PhD, RN, CNE, CIC, FAPIC Stanley Healy, MBA, DHA Karen Hoffmann, RN, MS, CIC, FSHEA, FAPIC Pat Metcalf Jackson, RN, MA, CIC, FAPIC Ann Marie Pettis, RN, BSN, CIC, FAPIC Barbara Smith, RN, BSN, MPA, CIC, FAPIC Katherine Ward, RN, BSN, MPH, CIC, FAPIC

EX OFFICIO Katrina Crist, MBA, CAE

DISCLAIMER Prevention Strategist is published by the Association for Professionals in Infection Control and Epidemiology, Inc. (“APIC”). All rights reserved. Reproduction, transmission, distribution, or copying in whole or in part of the contents without express written permission of APIC is prohibited. For reprint and other requests, please email editor@apic.org. APIC makes no representations about the accuracy, reliability, completeness, or timeliness of the material or about the results to be obtained from using this publication. You use the material at your own risk. APIC assumes no responsibility for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. Although all advertising material is expected to conform to ethical (medical) standards, inclusion in this publication does not constitute a guarantee or endorsement of the quality or value of such product or of the claims made of it by its manufacturer.


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CEO’S MESSAGE

A leadership mindset

ARE YOU A manager or a leader? Do you desire to be a leader?

All professionals are managers, but not all managers are leaders. Managers deal with the status quo, while leaders deal with change. Managers react to situations; leaders create opportunities. Managers coordinate efforts; leaders solve problems and focus on strategic alignment. Managers seek and then follow direction; leaders set direction and energize people to achieve it. The Center for Creative Leadership identifies the six most important leader competencies in order as: 1. Building collaborative relationships 2. Strategic perspective 3. Participative management 4. Change management 5. Leading employees 6. Taking initiative

BY KATRINA CRIST, MBA, CAE, APIC CEO

These are all highly relevant to the role of an infection preventionist (IP), and they are critical to increasing the value of the IP. Over the next year, APIC will map the desired future of the IP and update the IP competency model. Adopting and applying a leadership mindset will not only be desired, but necessary for IP professional development and competency moving forward. Vineet Nayar’s 2013 article in Harvard Business Review on leadership transitions described three ways for managers to assess whether they have crossed over from manager to leader. Ask yourself the following questions: • Are you counting value or creating value? • Do you have circles of power or circles of influence? • Are you managing work or leading people? In his conclusion, Nayar said, “When you stop discussing the tasks at hand—and talk about vision, purpose, and aspirations instead—that’s when you will know you have become a leader.” APIC will be bringing more and more forward on leadership development—take this issue of Prevention Strategist, for example. You will also see more leadership sessions at annual conference in Minneapolis. It is a continual process and career-long journey to develop and apply leadership. It all starts with a leadership mindset!

“Adopting and applying a leadership mindset will not only be desired, but necessary for IP professional development and competency moving forward.”

8 | WINTER 2017 | Prevention

Prevention W I N T E R 2 017 • VO L U M E 10 , I S S U E 4

PUBLISHER Katrina Crist, MBA, CAE kcrist@apic.org MANAGING EDITOR Rickey Dana editor@apic.org CONTRIBUTING EDITORS Elizabeth Garman Julie Blechman, MPH, CHES PROJECT MANAGER Russell Underwood runderwood@naylor.com ADVERTISING Brian Agnes bagnes@naylor.com GRAPHIC DESIGN Dan Proudley

EDITORIAL PANEL George Allen, PhD, CIC, CNOR, FAPIC Kristine Chafin, RN, MBA, CIC Edina Fredell, MPH, MT(ASCP), CIC Ruth Freshman, BSN, RN, CIC Kari Love, RN, BS, MSHS, CIC, FAPIC May Riley, RN, MSN, MPH, ACNP, CCRN, CIC, FAPIC Steven Schweon, RN, MPH, MSN, HEM, CIC, FSHEA, FAPIC Alexander Sundermann, MPH, CIC Christine Young-Ruckriegel, RN, MSN, MPA, CIC

CONTRIBUTING WRITERS Julie Blechman, MPH, CHES Rickey Dana Correen Dingle Elizabeth Garman Patricia Montgomery, MPH, RN, CIC Michelle Parisi Silvia Quevedo, CAE Christina Wahrmund, MSN, RN, CIC

MISSION APIC’s mission is to create a safer world through prevention of infection. The association’s more than 15,000 members direct infection prevention programs that save lives and improve the bottom line for hospitals and other healthcare facilities. APIC advances its mission through patient safety, implementation science, competencies and certification, advocacy, and data standardization. Visit APIC online at www.apic.org. PUBLISHED DECEMBER 2017 • API-Q0417 • 6851


CELEBRATING EXCELLENCE

7,000 and counting…

AS THE YEAR winds down, you have much to celebrate about certification. At the time of

BY LITA JO HENMAN, 2017 CBIC PRESIDENT, MPH, CIC

“When we give ourselves permission to fail, we, at the same time, give ourselves permission to excel.”

writing this article, we are on track to end 2017 with an estimated 7,000 CIC®-certified infection prevention professionals across the world! This is the highest number of certified infection preventionists (IPs) in the history of the Certification Board of Infection Control and Epidemiology, Inc. (CBIC). I’ve had the opportunity to speak to many IPs while traveling this year, and I continue to be inspired by the level of passion and commitment toward pursuing the highest level of professional skills and competence. No matter the patient population—outpatient endoscopy, behavioral health, long-term care, or inpatient facility—you always talked about your pride in becoming CIC-certified. You enthusiastically discussed what certification meant to you personally and professionally, and how it helped to ensure that all healthcare patients receive care in a way that minimized their risk of healthcare-associated infections. Some of you had full support, and sometimes incentive, from your employer to become certified, while others took motivation from internal sources or from peers. You’ve proven that regardless of the practice setting, certification is valuable to you and your patients. However, less than half of eligible IPs are currently certified. Surveys, focus studies, and group discussions have uncovered several barriers. Lack of financial support and unrecognized value of certification by healthcare administrators are often cited as reasons that keep IPs from becoming certified. One of the CBIC projects that I’m most excited about this year is the research that is being undertaken to help tear down these barriers. This project will take place over the next several months and will help us to quantify the value of certification to you, your facility, and your patient. This information will help build a business case for certification in terms that can be used to garner support for more IPs to become certified. One of the frequently unspoken barriers to obtaining certification has nothing to do with financial commitment or lack of employer support, but is so powerful that it stops many IPs from ever pursuing certification. What is this powerful force that prevents skilled and experienced IPs from demonstrating their competence? Fear of failure. Too many times, this commanding fear is at the heart of IPs not trying to become certified. Did you know about 70 percent of initial certificate holders are successful on their first certification exam? And that many of those who aren’t initially successful learn from that experience, revise preparation plans, and are successful on a later attempt. If fear of failing is proving to be a barrier to obtaining your CIC, create a written plan that includes step-by-step actions and a realistic timeline. Hand that plan to a colleague or friend who will help you keep on track, then watch that fear start to slowly drip away. Eloise Ristad voices this phenomenon well: “When we give ourselves permission to fail, we, at the same time, give ourselves permission to excel.” It has been my honor and pleasure to serve as the president of CBIC in 2017. I would like to extend my greatest appreciation to outgoing board members Chris Zirges, Connie Cutler, and Ruth Carrico. I applaud your generous and transformative leadership and will always value the lessons you’ve imparted. I am pleased that this tradition of inspired leadership will continue when Joann Andrews takes over as CBIC president in 2018.

Lita Jo Henman, MPH, CIC

10 | WINTER 2017 | Prevention


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BRIEFS TO KEEP YOU IN-THE-KNOW

Meet the 2017 Heroes of Infection Prevention CHRISTINA EWERS, MS, RN, CIC

Visit the Heroes web page to read profiles of each Hero. www.apic.org/About-APIC/Awards/Heroes. The Heroes program is supported by a grant from BD, an APIC Strategic Partner

LUTHERAN MEDICAL CENTER (PART OF SCL HEALTH) WHEAT RIDGE, COLORADO

Eliminating blame to create transparency and solutions AFTER LAUNCHING A pilot infection prevention pro-

gram for the state of New Mexico, Christina Ewers decided to make the switch from public health to infection prevention. “I realized I didn’t want to just collect data—I wanted to be able to impact patient health,” she said. The pilot project also gave Ewers first-hand experience with a systems approach for infection prevention. Her current employer, SCL Health, uses tools of high-reliability organizations, including emphasis on a systems approach to prevent accidents and improve safety. “I found this approach to be really valuable because it emphasizes objective analysis as well as system vs. individual failures,” Ewers said. “When problem-solving is about processes instead of people, people can be more transparent. We talk about what went wrong with the process instead of, ‘This is what you did wrong.’”

Ewers used this approach to successfully tackle central line-associated bloodstream infections (CLABSI) at Lutheran Medical Center (LMC). After conducting a common cause analysis and identifying trends between CLABSI cases, she engaged facility partners to help identify gaps as well as problems with central-line processes and conditions. The team then worked together to develop interventions that would address these gaps. After initiating the CLABSI campaign, LMC went more than a year without an adult CLABSI. Ewers is now utilizing the same approach to attack catheter-associated urinary tract infections and C. difficile. “This approach allows for flexibility depending on the problem you’re trying to solve,” she said. “Your team changes, but the approach is the same.” Ewers, who serves on the board for APIC Mile High Chapter 22, emphasizes the importance of APIC involvement for anyone in an infection prevention role. “Attending my local meeting every month has been tremendously valuable,” she said. “I could not do this job alone.”

ELAINE WHALEY, MSN, RN, CIC, CPHQ

TEXAS CHILDREN’S HOSPITAL HOUSTON, TEXAS

ANGELA RUPP, MT, MS, CIC, FAPIC

ANN & ROBERT H. LURIE CHILDREN’S HOSPITAL OF CHICAGO, CHICAGO, ILLINOIS

Collaborating to connect dots and save lives IN FEBRUARY 2016, Elaine Whaley’s Texas-

based pediatric hospital identified a cluster of Burkholderia cepacia (B. cepacia) among their pediatric non-cystic fibrosis (CF) patients. Just a few weeks later, Angela Rupp’s Chicago-based pediatric facility also identified a B. cepacia cluster. Both professionals sent B. cepacia isolates to the Cystic Fibrosis Foundation Research Laboratory (the national repository for these isolates) for verification and genotyping, and the laboratory responded with two valuable pieces of information: The isolate was not the same B. cepacia organism previously seen in either hospital’s patients, and there was another hospital in the country battling the same organism. Due to confidentiality, however, the Foundation could not disclose facility names. Fortunately, Whaley and Rupp had connected years before through the Children’s Hospital Association (CHA) infection prevention directors’ forum, and had worked together during the Ebola crisis. 12 | WINTER 2017 | Prevention

When Whaley learned that the second B. cepacia cluster was in Chicago, she contacted Rupp to determine if— by chance—it was her facility. The two professionals then combined their data, analysis, and research efforts. “Knowing each other let us focus our efforts much more quickly,” Rupp said. They also continued leveraging their professional relationships, alerting CHA infection prevention listserv colleagues to the outbreak and subsequently identifying additional B. cepacia clusters. By comparing identical or similar supplies and medications used at their facilities, along with some “pretty slick” analysis, Whaley and Rupp quickly and efficiently identified a common, contaminated product. “We made the internal decision to stop using this medication immediately,” said Rupp. Whaley and Rupp’s findings subsequently resulted in an FDA recall, preventing countless cases of infection. “I can’t stress enough the importance of professional relationships,” Whaley said. “It’s much easier to pick up the phone and ask a colleague about an outbreak when you’ve developed these relationships over time.”


JAMIE SWIFT, RN, BSN, CIC, FAPIC

MOUNTAIN STATES HEALTH ALLIANCE JOHNSON CITY, TENNESSEE

Impacting the health of a region AN INFECTION PREVENTION specialist since 2001,

Jamie Swift is inspired by the problem-solving that her job requires. “It’s one thing to sit back and see something that can be changed and another to actually try to change it,” she said. Swift’s problem-solving capabilities—as well as her leadership, influence, and tenacity—have had a significant, positive impact on the health and safety of her Tennessee community. In 2014 and 2015, she spearheaded an effort that earned her health system the first “Tennessee Highly Infectious Disease Treatment Network” designation. The initiative was far-reaching, and involved training all 13 hospitals in the Mountain States Health Alliance health system (MSHA)—as well as the Level I Trauma Center—to identify and control Ebola. Swift’s leadership and advocacy also have resulted in the development and deployment of sustained community prevention and

response programs addressing threats such as measles, Zika, and the flu. She highlights senior leadership buy-in as a critical component of any IP program, and her approach to securing this buy-in is grounded in logic and compassion: “If we can effectively communicate that what we’re doing is for patient safety, it’s easier to gain support.” By consistently providing encouragement and support to her infection prevention and control (IPC) team, even in high-pressure situations, Swift not only improves the team’s performance, but also serves as a role model for IPC leadership. “When I see stress in my staff, it triggers me,” she said. “We’re going to be so much more productive if we take a break, step away, and come back in 30 minutes.” Swift advises other IPC professionals to develop relationships not only within their own organizations, but with other networks and hospitals in their regions. “There’s so much going on with IPC that we cannot figure it out on our own,” she said.

CDC funds new efforts for infectious disease threats U.S. Antibiotic Awareness Week

ON AUGUST 4, the Centers for Disease Control and Prevention

TO KICK OFF U.S. Antibiotic Awareness Week (formerly “Get

(CDC) announced it would invest more than $200 million to help states detect and respond to infectious disease threats. The funding comes from the Antibiotic Resistance Solutions Initiative, and the Epidemiology and Laboratory Capacity for Infectious Diseases cooperative agreement.

www.cdc.gov/antibiotic-use.

Key elements of the programs include: • $77 million to help state health departments fight local antibiotic resistance threats; • enhancing the Antibiotic Resistance Laboratory Network; • establishing and maintaining local, state, and territorial health coordinators to track vaccine-preventable diseases; • helping states build their capacity for Advanced Molecular Detection; and • continuing efforts against Zika virus outbreaks and associated adverse health outcomes. To learn more about this effort, visit https://www.cdc.gov/media/ releases/2017/p0804-200-million.html.

Smart About Antibiotics Week”) on November 13, the Centers for Disease Control and Prevention (CDC) launched Be Antibiotics Aware, an educational effort to raise awareness about the importance of safe antibiotic prescribing and use. The new initiative provides resources to help improve antibiotic prescribing among healthcare professionals, focusing on prescribing antibiotics only when needed, and at the right dose for the right duration and at the right time. U.S. Antibiotic Awareness Week was observed November 13-19, 2017. For resources to help healthcare professionals (in outpatient and inpatient settings) educate patients and families about antibiotic use and risks for potential side effects, visit

w w w.apic.org | 13


BRIEFS TO KEEP YOU IN-THE-KNOW

ICYMI: APIC MegaSurvey RESULTS FROM THE APIC 2015-16 MegaSurvey, the largest-ever survey of the infection prevention workforce, describe the core activities and compe-

tencies of infection preventionists (IPs). APIC undertook the MegaSurvey in 2015 to create a baseline of data for a better understanding of IP roles and responsibilities by facility type, years of experience, and current position. Having collected baseline data, APIC plans to build on it by periodically re-deploying the MegaSurvey. Be sure and read these open-access articles, based on the survey findings, published in the June 2017 issue of the American Journal of Infection Control (AJIC), in addition to the overview article published in January 2017:

Understanding the current state of infection preventionists through competency, role, and activity self-assessment (Kalp EL, Marx JF, Davis J. Am J Infect Ctrl, 2017;45(6):589-596.) Differences in self-rated competency were identified for each of the eight IP core competency activities. IPs report using various resource types to gain competency. Future research is needed to identify opportunities to increase competency levels in the weakest-rated competency activities.

Infection Prevention Outside of Acute Care Setting: Results from the MegaSurvey of Infection Preventionists

Infection prevention outside of the acute care setting: Results from the MegaSurvey of infection preventionists (Pogorzelska-Maziarz M, Kalp EL. Am J Infect Ctrl, 2017;45(6):587-602.) In recent years, there has been a significant shift of healthcare delivery from acute care hospitals to long-term and ambulatory care settings. Findings from the APIC MegaSurvey indicate the need for additional resources directed to IPC across different types of non-acute care settings and identified important areas for IPC education and program improvement.

2015 APIC MegaSurvey ofof4,079 (IP): 2015 APIC MegaSurvey 4,079Infection Infection Preventionists Preventionists (IP): Hiring IPs with Diverse Background Would Address Expanding Roles Hiring IPs with Diverse Backgrounds Would Address Expanding R Roles oles

Infection prevention workforce: Potential benefits to educational diversity (Reese SM, Gilmartin HM. Am J Infect Ctrl, 2017;45(6):603-606.) Infection control departments would benefit from hiring IPs with diverse education and training to address the expanding roles and responsibilities of IPs. This may facilitate the implementation of novel and innovative processes that will impact patient care.

PROFESSIONAL BACKGROUND

82% Nurses

EDUCATIONAL BACKGROUND

72%

WORK ACTIVITIES

30%

41%

97% Prevention and Control of Infections

10% Laboratory Scientists

60%

40%

71%

98% Surveillance

5% Public Health

29%

71%

54%

96% Management & C i ti Communication

Reese & Gilmartin, Gilmartin AJIC June 2017 doi.org/10.1016/j.ajic.2017.03.029.

14 | WINTER 2017 | Prevention


MEGASURVEY DATA REPORTS AVAILABLE IN THE APIC STORE GET THE LATEST data on IP practices and competencies, organizational structure, and compensation in reports from the APIC MegaSurvey. These digital reports may be ordered individually or as a bundle.

The Practices and Competencies Report allows organizations and individuals to compare key aspects of their roles and responsibilities to those of their peers in eight key areas of IP competency.

The Organizational Structure Report provides detailed information about infection prevention and control (IPC) programs in healthcare facilities including acute care, ambulatory surgery centers, long-term care, dialysis centers, Veterans Affairs, behavioral health, military, and others. Results are broken out by primary responsibility of the IP.

The Compensation Report (made available free to APIC members who participated in the survey) allows you to benchmark compensation levels and is a useful tool during the recruitment process. The Compensation Survey Dashboard allows easier and customized access to baseline compensation data.

All four digital MegaSurvey products are available for purchase at www.apic.org/APICstore/Products.

NEW! Your go-to collection of infection prevention tools and resources FORMS & CHECKLISTS FOR INFECTION PREVENTION VOLUME 1 AND VOLUME 2 were developed to be your go-to resources for helpful forms,

checklists, policies, guidelines, tools, posters, and other resources to assist you and your organization with key infection prevention and control process and reporting activities. FORMS & CHECKLISTS FOR INFECTION PREVENTION, VOLUME 1

FORMS & CHECKLISTS FOR INFECTION PREVENTION, VOLUME 2

Sections on infection prevention programs, infection prevention education, surveillance, precautions, performance improvement, and environment of care, plus appendix and section resources.

Sections on patient care policies, department policies, occupational health, construction and renovation, and long-term care, plus appendix and section resources.

Content includes: • Orientation tools and position descriptions; • Data collection and analysis tools for investigations; • Needs assessments, gap and root cause analyses, action plans; and • Cleaning and rounding checklists including staff training.

VOLUME 2

Content includes: • A range of department policies from the pharmacy to operating and emergency rooms; • Job hazard analysis forms and occupational health policies, such as sharps disposal and PPE glove use; • ICRA and other construction & renovation forms; and • Antibiotic stewardship tools for long-term care facilities.

Both publications are available in print and digital formats. Visit www.apic.org/store to learn more and to place your order. w w w.apic.org | 15


BRIEFS TO KEEP YOU IN-THE-KNOW

Potential shift to sterilization of endoscopes APIC PRESIDENT LINDA GREENE and Practice

Guidance Committee member Kathleen McMullen participated in an Association for the Advancement of Medical Instrumentation (AAMI) Stakeholder meeting to discuss a possible shift from high-level disinfection (HLD) to sterilization of endoscopes. The meeting was convened by AAMI and included representation from more the 40 stakeholders. The group discussed the potential changes to the Spaulding classification for endoscopes to critical (requiring sterilization) versus semi-critical (requiring HLD). Evidence on the need to move to endoscope sterilization was provided by Dr. Bill Rutala, Dr. Cori Ofstead, and Dr. Michelle Alfa. Continued deliberation was conducted during the AAMI ST 91: Flexible and semi-rigid endoscope processing in healthcare facilities workgroup meeting in October. To read the news article on potential new guidance from the AAMI ST 91, go to www.aami.org/newsviews/newsdetail. aspx?ItemNumber=5243.

Upgraded online learning platform ABCs of Antibiotics A GROWING LIST of infections are becoming harder to treat as antibiotics become

less effective. APIC’s newest infographic, The ABCs of Prescribing Antibiotics, will help healthcare professionals prevent the spread of antibiotic-resistant bacteria. This infographic complements The ABCs of Antibiotics for patients and families. These resources were developed in collaboration with APIC’s Communications Committee. Share them both with your team and your patients: http://professionals.site.apic.org/infographic/abcs-of-antibiotics/.

16 | WINTER 2017 | Prevention

APIC’S UPGRADED ONLINE learning platform

provides a unique education experience— seamless functionality, interactive discussion boards and knowledge checks, an enhanced transcript, and more. Nothing has changed regarding accessibility. You are still in control to choose the time, place, and pace that works best for your schedule. We simply wanted to enrich your online learning experience to make the biggest impact on your professional development! To view the current catalog and enroll, visit www.apic.org/anywhere.


When to HLD with trophon®

Disinfection / Sterilization Requirements

Spaulding Classification

Procedure

What Procedure WIll your Probe be uSed for?

Probe may contact sterile tissue or blood

Probe may contact mucous membranes and non intact skin

Probe will only contact healthy, intact skin

Critical

Semi-Critical

Non-Critical

• intraoperative procedures • drainages • biopsies • needle guidance • transvaginal oocyte retrieval • venous catheter placement • vascular ablation

Intracavity • transvaginal scans • transrectal scans

• surface ultrasound (intact skin)

Sterilize* or HLD

HLD

Surface ultrasound (broken skin) • wound scanning • burn evaluation

LLD or HLD

Probe haS been troPhoned and IS ready for uSe *Critical probes should be sterilized, or can also be high level disinfected and used with a sterile sheath. Note: The use of a sheath does not negate the need for HLD.1

Making the choice simple For outstanding ultrasound probe HLD compliance.

MM0522-US-AD V01

to download your own free printable version of this chart, please visit: http://info.nanosonics.us/when-to-hld-guide


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CIC PROFILE

Meet a CIC

PATTY MONTGOMERY, MPH, RN, CIC Nurse Consultant, Infection Control Assessment and Response (ICAR) – Project Lead Washington State Department of Health Shoreline, Washington

“The best advice I have given is that you know more than you think you do, so trust yourself.”

Q:

WHAT INSPIRED YOU TO BECOME AN INFECTION PREVENTIONIST (IP)?

My father-in-law, a surgeon, developed a MRSA surgical site infection postbunionectomy and almost lost his foot. Seeing someone I love experience a preventable infection made me realize how important the work of an IP is, and inspired me to go back to school and make infection prevention a career.

Q: Q:

HOW LONG HAVE YOU BEEN AN IP? I have been an IP for five years.

WHY IS MAINTAINING BOARD CERTIFICATION IN INFECTION PREVENTION AND CONTROL (CIC) IMPORTANT TO YOU?

I work as a public health nurse consultant for the Washington State Department of Health, where my primary role is to provide infection prevention expertise to healthcare facilities across the state of Washington. It’s critical that healthcare facilities feel wellsupported for day-to-day infection prevention guidance and in outbreak situations. Since I perform infection prevention site visits at different types of healthcare facilities, it’s especially important that my comprehension of infection prevention is well-rounded. CIC content can be applied to so many healthcare settings—outpatient, long-term care, hospitals, and dialysis. Maintaining the CIC board designation demonstrates that I have a fundamental understanding of infection prevention knowledge and practices.

Q:

HOW DID YOU PREPARE FOR THE CIC EXAM? WHAT HELPED?

The first thing I did was to schedule the test three months out. Having the test date set motivated me to focus on my preparation efforts. I did practice test taking by taking the first practice test to get a baseline of where I needed to focus my attention, and every couple of weeks I would take another to track progress. The practice tests were helpful, but I learn better in group environments, so I started a study group within my APIC Chapter - Puget Sound 062. To kick off the study group, I scheduled weekly webinar study sessions and invited my infection prevention and public health colleagues to participate. For each session, I presented study questions from the APIC Certification Study Guide, 6th edition using a PowerPoint w w w.apic.org | 19


presentation. Every week, I focused on a new chapter from the study guide. Planning for the webinars helped prepare me for the CIC exam. Edgar Dale, an American educator, once said, “We remember 95 percent of what we teach.” I don’t know if I remembered 95 percent of what I presented to the study group, but it certainly helped me engage in an active learning mode. Now that I’m certified, my involvement in the webinar study group continues. We started out with

eight attendees, and we now have over 50 participants who attend the webinar-based study group.

Q:

IN WHAT WAYS HAS YOUR CIC BENEFITED YOU?

The CIC benefits me every time I walk in the door to a new facility to do an ICAR site visit. During outbreaks I often visit or talk with

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Traditionally, public health has not been funded to conduct infection prevention outreach and assistance. Thanks to grant funding from the Centers for Disease Control and Prevention (CDC), we were able to bolster Washington State Department of Health’s ability to be a resource to healthcare facilities in our community. Having a CIC is a marker for expertise. This has improved the Department of Health’s ability to perform effective outreach to IPs across the state.

WHAT IS THE BEST ADVICE YOU HAVE EVER RECEIVED? WHAT IS THE BEST YOU HAVE EVER GIVEN?

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Schedule the test. The test date is a tangible goal, and motivated me to charge ahead and study consistently. Practice the questions; even when you get the answers wrong, you are teaching yourself how to guess when you don’t know the answer, which does happen. Take the long practice tests and keep track of your results. Remember, you don’t have to know everything to pass. Lastly, be sure to celebrate when you become certified. A CIC designation is something to be proud of and celebrate. It’s a personal achievement and benefit to your employer.

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the facility IP to help with risk assessments and strategize how to prevent transmission. The leadership and the IP at the facility can trust that I have a comprehensive understanding of infection prevention and am a reliable source of information. Having the CIC gives me confidence and has made me a better IP.

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APIC CONSULTANT CORNER

Being an interim IP A CONVERSATION WITH CHRISTINA “TINA” WAHRMUND, MSN, RN, CIC

lease explain what an interim infection ✦ Ppreventionist (IP) is. An interim IP is a leader in the field of infection prevention and epidemiology, utilizing expert knowledge and critical thinking skills to meet the needs and goals of a client during a specified timeframe. As well as being a subject matter expert, the interim IP must be autonomous and possess strong leadership skills.

us the type of work or assignment that ✦ Tanellinterim IP would do. An interim IP works in myriad assignments including interim work, program management, outbreak investigation, on-site education, and training, crisis intervention, survey preparedness, surveillance, and National Health Safety Network (NHSN) auditing for a temporary, pre-determined timeframe.

✦ What type of facility would need an interim IP?

 e would be anywhere that would have a possibility of W infection. Settings can vary from acute care, dialysis centers, rehabilitation, and behavioral health, to long-term care, outpatient facilities, and clinics. For instance, various types of outpatient facilities may include surgical centers, oncology units, gastroenterology clinics, dental offices, and emergency care centers. Therefore, each assignment is different, offering a new set of challenges and rewards.

nder what circumstances would a facility ✦ Uneed an interim IP? This would be in situations to fill an IP vacancy caused by illness, death, or staff department. Sometimes a facility may require the assistance of an interim IP for project analysis, project or program management, or project development, performance improvement, NHSN surveillance, regulatory compliance, and analysis of descriptive epidemiology in an outbreak investigation.  Unfortunately, there are instances when leaders at a facility are not aware that they require the assistance of an interim IP and believe they can solve the issue without additional assistance; consequently, this may cause the problem to escalate. 22 | WINTER 2017 | Prevention

escribe how a facility can most effectively ✦ Dutilize an interim IP. In short, staff of the facility should be open and ready to learn. We look for teachable moments, and in doing so, we’re able to provide the best recommendations for building or improving a program.  Aside from the circumstances I mentioned earlier, an interim IP would be great during new IP orientation and mentoring, onsite education and training, or special projects, such as antibiotic stewardship. We can also author documents, such as an infection control plan, risk assessment, policies and procedures, and infection control risk assessment (ICRA) for construction.

an experience you had as an interim IP and ✦ Dtheescribe value you were able to bring to the facility. I was working with a hospital system in survey preparedness, and on a Friday night, after leaving for the day and driving four hours to my home, I received an emergency call from the hospital CEO, COO, and director of quality. The hospital developed a massive water leak in the basement of the hospital where the kitchen, sterile processing, central supply, outpatient therapy, and the morgue were located. They were requesting my expertise onsite to assist with the “how” and “what” for cleaning and sterilization (i.e., guidelines, best practices, and processes). In response, I threw clean clothes in my suitcase and drove back to the hospital. On my arrival, the plant engineer was desperately trying to pump standing brown water out of the basement. Obviously, administration was extremely grateful that I returned back to the hospital to offer my assistance.  For my current assignment, I am working with a large hospital system developing an infection prevention program for their 22 outpatient clinics. Part of my role is to support the director of infection control at the inpatient hospital. Because a good, team-working relationship is imperative for a strong infection prevention program, I focus on providing research and documentation on guidelines and best practices, rather than leading.


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CAPITOL COMMENTS

Certification—the new expectation for IPs BY RICH CAPPARELL, NANCY HAILPERN, AND LISA TOMLINSON

APIC’S STRATEGIC PLAN 2020 (SP 2020) set a

Greater confidence and opportunity Professional certifications are required for many industries and are particularly prevalent in healthcare. Similar to board certification for physicians, certification in a wide range of fields–from finance to education–is now an expectation for employment. Certification is seen as a win-win for employers, employees, and other key stakeholders, and is becoming the norm as employers seek an edge in their industry and hiring managers look for applicants who have demonstrated a willingness to invest in their careers. This can provide greater confidence in identifying candidates, and give an opportunity for IPs to show their qualifications and dedication.

Better outcomes for patients There is growing evidence that IPs with a CIC have better patient outcomes. According to studies, hospitals whose

PHOTO CREDIT: ORHAN CAM/SHUTTERSTOCK.COM

goal for infection preventionists (IPs) related to competencies and certification that called on the organization to “Define, develop, strengthen, and sustain competencies of the IP across the career span and support board certification in infection prevention and control (CIC ®) to obtain widespread adoption.” In response to SP 2020, APIC set the following desired outcomes: • The majority of IPs will demonstrate core competency in infection prevention and control through board certification. • The role and value of IPs will be strengthened through greater adoption of a standardized credential. To measure progress toward these outcomes, the organization’s leadership developed an ambitious 2020 target of 10,000 CICs, and began measuring progress toward that goal in 2012.

“Professional certifications are required for many industries and are particularly prevalent in healthcare. Similar to board certification for physicians, certification in a wide range of fields is now an expectation for employment.” infection prevention and control (IPC) programs are led by a CIC have significantly lower rates of methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections, and lower rates of catheter-related bloodstream infections.1-2 Credentialed IPs

are two to three times more likely to perceive the evidence of certain infection prevention practices as strong. This perception of evidence may explain why certified IPs are more likely to implement certain infection control measures.3 Furthermore, research has w w w.apic.org | 25


CAPITOL COMMENTS shown, IPs with a CIC are better prepared to interpret evidence and act as champions for key infection prevention practices within their facility.2

An expanded and varied role APIC is constantly evaluating the future of infection prevention and the role IPs will play in healthcare for years to come. Since the early 2000s, there has been a greater emphasis on evidence-based medicine and better outcomes for patients, putting infection prevention front and center in the C-suite, and with state and federal policymakers. At the same time, IPs come to the profession from a variety of disciplines, backgrounds, and pathways to the profession. This may raise the question for healthcare leaders of “how do we know this individual has the knowledge to serve as an IP in our facility?” CIC is the only recognized credential that ensures that someone working as an IP is knowledgeable in the

field. Is it possible for individuals without such a credential to be competent and knowledgeable? Yes, of course. But the Certification Board of Infection Control & Epidemiology, Inc. (CBIC ®) is the only CIC credentialing body that fairly tests for such knowledge. The level of variation in the role of an IP also impedes recognition by state and federal policymakers. When you look at most state and federal statutes, the role of an IP is ill-defined at best, and in most cases does not exist. With little standardization within facilities, and state and federal authorities, the role and expertise of the IP is widely misunderstood or even overlooked. The inconsistency from region to region could have long-term impacts on the field of IPC and the future of IPs in the healthcare field. Setting the expectation that new entrants to the field become certified provides healthcare facilities and patients with a universal baseline of knowledge.

With that baseline, IPs can better craft the future of their role in healthcare.

Phasing in a certification requirement for new IPs During its fall meeting, the APIC Board of Directors supported a plan to begin a conversation with the APIC membership about phasing in a CIC certification requirement for new IPs. We look forward to further conversations with you about this approach in the coming years. For comments or questions about legislative proposals regarding mandatory certification, please contact the APIC Public Policy team at legislation@apic.org. References 1. Pogorzelska M, Stone PW, Larson EL. Certification in infection control matters: Impact of infection control department characteristics and policies on rates of multidrug-resistant infections. Am J Infect Control 2012;40(2):96-101. 2. Krein SL, Hofer TP, Kowalski CP, et al. Use of central venous catheter-related bloodstream infection prevention practices by US hospitals. Mayo Clin Proc 2007; 82: 672-678. 3. Saint S, Greene MT, Olmsted RN, et al. Perceived strength of evidence supporting practices to prevent health care-associated infection: results from a national survey of infection prevention personnel. Am J Infect Control 2013;41(2):100-6.

TABLE 1: STATE CIC® REQUIREMENTS

State

Colorado CO §25-3-602

Nevada NV ST 439.873

New Jersey N.J.A.C. 8:43G–14.3

26 | WINTER 2017 | Prevention

Summary of Code Related to CIC An individual who collects data on healthcare-associated infection rates shall take the test for the appropriate national certification for infection control and become certified within six months after the individual becomes eligible to take the certification test, as recommended by the Certification Board of Infection Control and Epidemiology, Inc., or its successor. Mandatory national certification requirements shall not apply to individuals collecting data on healthcare-associated infections in hospitals licensed for fifty beds or less, licensed ambulatory surgical centers, licensed dialysis treatment centers, licensed long-term care facilities, and other licensed or certified health facilities specified by the department. Qualifications for these individuals may be met through ongoing education, training, experience, or certification, as defined by the department. If a medical facility has 175 or more beds, the person who is designated as the infection control officer of the medical facility must be certified as an infection preventionist by the Certification Board of Infection Control and Epidemiology, Inc., or a successor organization. A person may serve as the certified infection preventionist for more than one medical facility if the facilities have common ownership.

The infection control professional shall have education or training in surveillance, prevention, and control of nosocomial infections. The infection control professional shall be certified in infection control within five years of beginning practice of infection control and shall maintain certification through the Certification Board of Infection Control, Inc.


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1. Mullen A, et al. Perioperative participation of orthopedic patients and surgical staff. AJIC, 2017: Vol 45, Issue 5, 554 - 6. 2. Huang SS et al. Targeted versus universal. N Engl J Med, 2013: 368(24): 2255-65. Mupirocin and CHG used in study. 3. Steed L, et al. Reduction of nasal Staphylococcus aureus carriage. AJIC, 2014: 42(8): 841-846. ©2017 Global Life Technologies Corp. All rights reserved. Made in USA. Nozin®, Nasal Sanitizer®, Nasal decolonization is the key™, 360™, Leader in Nasal Decolonization™ are trademarks of Global Life Technologies Corp. Nozin® Nasal Sanitizer® antiseptic is an OTC topical drug and no claim is made that it has an effect on any specific disease.


PREVENTION IN ACTION

MY BUGABOO

Common etiologic agents of pneumonia:

Information for busy infection preventionists

KATERYNA KON/SHUTTERSTOCK.COM

BY IRENA KENNELEY, PHD, RN, CNE, CIC, FAPIC

GREETINGS FELLOW INFECTION PREVENTIONISTS! THE SCIENCE OF infectious diseases involves hundreds of bacteria, viruses, fungi, and protozoa. The amount of information available

about microbial organisms poses a special problem to infection preventionists (IPs). Obviously, the impact of microbial disease cannot be overstated. Traditionally, the teaching of microbiology has been based mostly on memorization of facts (the “bug parade”). Too much information makes it difficult to tease out what is important and directly applicable to practice. This quarter’s My Bugaboo column features information about the organisms that commonly cause pneumonia. The intention is to convey succinct information to busy IPs for common etiologic agents of healthcare-associated infections. Please feel free to contact the author with questions, suggestions, and comments at irena@case.edu.

28 | WINTER 2017 | Prevention


OVERVIEW

The most common portal of entry for many infectious organisms is the respiratory route. The microbiome of the respiratory system is dependent on microbial entry and microbial elimination. The respiratory microbiome’s role serves a protective function in that the resident organisms compete for space and nutrients, which is known as microbial antagonism. In a healthy microbiome, pathogens do not have as much of an opportunity to attach and grow. Infections in the respiratory tract can result when the lung microbiome is disturbed or out of balance; for example, due to immunosuppression.1 Until recently, it was thought that the lower respiratory system (LRT) was a sterile environment, but through many DNA sequence analyses, we now know that the LRT is not without microbes. Actually, the LRT has a microbiome, but it is about 1,000 times less dense than the microbiome of

the upper respiratory system.1 Table 1 shows common organisms that cause pneumonia, while Table 2 lists common organisms found in the respiratory system.

with the highest risk factors include older adults and the immunosuppressed.

SIGNIFICANCE AND RISK FACTORS

MAJOR BACTERIAL ORGANISMS CAUSING LOWER RESPIRATORY INFECTIONS

In the United States, there are two to three million infections resulting in pneumonia, which lead to 45,000 deaths each year.1 This includes both community-associated and healthcare-associated infections (HAIs). Urinary tract infections are the most common HAI, and pneumonia is the second most common. Most cases of healthcareassociated pneumonia (HCAP) occur with mechanical ventilation. Several bacterial species are associated with ventilator-associated pneumonia (VAP), and many of these show increasing antibiotic resistance. HCAP is defined as an inflammation of one or both lungs at least 48 hours after admission to a healthcare facility. Those

HAPs are caused by several bacterial organisms. The most common bacterial organisms associated with the HAI pneumonia are listed below. (The list of organisms included in this article is not exhaustive. The most common organisms to cause pneumonia have been included.)2,3 • Klebsiella pneumoniae • Pseudomonas aeruginosa • Acinetobacter baumanii • Escherichia coli, Enterobacter spp., Proteus spp., Serratia marcescens • Staphylococcus aureus • Streptococcus pneumoniae The most common community-associated bacterial organism causing pneumonia is

TABLE 1. OVERVIEW OF COMMON ORGANISMS THAT CAUSE PNEUMONIA

Disease Pertussis Tuberculosis

Etiologic Agent Bordetella pertussis Mycobacterium tuberculosis HealthcareKlebsiella pneumonia associated Pseudomonas aeruginosa pneumonia (HCAP) Staphylococcus aureus (common) Streptococcus pneumoniae CommunityStreptococcus pneumoniae associated pneumonia (CAP) Atypical pneumonia Legionella pneumonia (can be an HAI) Mycoplasma pneumoniae Influenza

Influenza A, B, C

RSV

Respiratory syncytial virus Human metapneumovirus Human parainfluenza viruses 1 and 3 SARS coronavirus (SARS-CoV) MERS coronavirus (MERS-CoV) Aspergilllus fumigatus

RSV-like illness Parainfluenza SARS/MERS

Aspergillosis

Transmission Route Respiratory droplets Respiratory droplets

Treatment Erythromycin Combination antibiotic therapy Antibiotics

Prevention Vaccination DTaP, TdaP Preventing exposure to active TB patients Good hand hygiene

Respiratory droplets

Penicillin Cefotaxime

Vaccination Good hand hygiene

Respiratory droplets via water systems, whirlpool spas, air conditioning systems Respiratory droplets

Antibiotics

Cleaning and disinfection of water systems, pools, spas

Bed rest, supportive therapy Ribavirin for severe cases Ribavirin for severe cases Supportive therapy

Annual flu vaccine

Supportive therapy No effective treatment

Good hand hygiene

Antifungal voriconazole

Avoiding the creation of spores/ cleaning mold

Respiratory droplets

Respiratory droplets Hand contact Respiratory droplets Direct contact Respiratory droplets Direct contact Respiratory droplets Airborne particles Direct contact Airborne spores

Good hand hygiene Good hand hygiene Good hand hygiene

w w w.apic.org | 29


PREVENTION IN ACTION

TABLE 2. HUMAN MICROBIOME ORGANISMS OF THE RESPIRATORY TRACT

Phylum

Genera Present

Actinobacteria

Corynebacterium, Propionibacterium

Firmicutes

Alloiococcus, Clostridium, Lactobacillus, Staphylococcus, Streptococcus

Proteobacteria

Campylobacter, Haemophilus, Neisseria, Pasteurella,

Bacteroides

Bacteroides

Streptococcus pneumoniae; Haemophilus influenzae is an example. Etiologic agents of atypical community-associated pneumonia, such as Legionella pneumophila and Mycoplasma pneumoniae, are usually prevalent during the summer and winter months. Bordetella pertussis and Mycobacterium tuberculosis are also CAIs.2,3 VIRAL ORGANISMS

Bacterial organisms are not the only agents that can cause pneumonia. Viruses and fungi are etiologic agents as well. In the United States, the most common cause of viral pneumonias is the influenza virus and respiratory syncytial virus (RSV).2 Human metapneumovirus (hMPV) is very similar

READ MORE ABOUT PNEUMONIA IN THE AMERICAN JOURNAL OF INFECTION CONTROL Prevalence of and outcomes from Staphylococcus aureus pneumonia among hospitalized patients in the United States, 2009-2012. Jacobs DM, Shaver A, American Journal of Infection Control, Vol. 45, Issue 4, p404–409. Risk factors and mortality of patients with nosocomial carbapenem-resistant Acinetobacter baumannii pneumonia. Zheng Y, Wan Y, Zhou L, et al., American Journal of Infection Control, Vol. 41, Issue 7, e59–e63. Microbiology and prognostic factors of hospital- and community-acquired aspiration pneumonia in respiratory intensive care unit. Wei C, Cheng Z, Zhang L, et al., American Journal of Infection Control, Vol. 41, Issue 10, p880–884.

30 | WINTER 2017 | Prevention

to RSV. Experts believe that by age 10, most children have been infected. Pneumonias caused by hMPV also occur in adults, as evidenced by two outbreaks in skilled nursing facilities in West Virginia (2011) and Idaho (2012). There were 57 cases, and six patients died.1 Other severe but less common viral pneumonias are caused by the following organisms: • Parainfluenza • Severe acute respiratory syndrome (SARS) • Middle East respiratory syndrome (MERS) • Hantavirus pulmonary syndrome FUNGAL ORGANISMS

The human fungal organisms (mycobiome) present in the human microbiome is an emerging field of study. To date, some 100 species have been identified in the oral cavity.1 The fungi are found in every ecosystem, and are mostly involved in degrading and recycling the biomass. The most common form of nonbacterial pneumonia in Americans occurs in patients with HIV/AIDS. It is Pneumocystis jiroveciii (formerly called carinii), or Pneumocystis pneumonia (PCP). The organism is transmitted person to person by airborne respiratory droplets, but there have been cases that were environmentally transmitted. This type of pneumonia can cause lethal infections where the alveoli contain dense masses of the organism and eventually death occurs through respiratory failure. Aspergillosis is an infection caused by a common mold (a type of fungus) both indoors and outdoors. Most people breathe the spores of Aspergillus every day without getting sick. However, people who are immunosuppressed are at higher risk. There have been reports of healthcare-associated Aspergillus fumigatus, especially during construction where patients are still in the units and protections have not been put in place to prevent the spread of spores.

“Until recently, it was thought that the lower respiratory system (LRT) was a sterile environment, but through many DNA sequence analyses, we now know that the LRT is not without microbes.” THE INFECTION PREVENTIONIST’S ROLE IN PREVENTION

• Surveillance for bacterial pneumonia in intensive care unit patients who are at high risk for HAI pneumonia (such as ventilated patients). • Educating staff and assuring their involvement and buy-in to practice infection prevention interventions. • Sterilization or disinfection and maintenance of equipment and devices. • Prevention of person-to-person transmission of bacteria. o Hand hygiene o Gowning o Care of tracheostomy under aseptic conditions o Suctioning of respiratory tract secretions For more information and detailed guidelines, please see the references section for the Guidelines for Preventing HealthcareAssociated Pneumonia. This document offers best practices to prevent pneumonia. Irena Kenneley, PhD, RN, CIC, FAPIC, is a professor at Case Western Reserve University, Frances Payne Bolton School of Nursing in Cleveland, Ohio. She serves on the APIC Board of Directors and is a past member of the Prevention Strategist editorial panel. References 1. Pommerville JC. Fundamentals of Microbiology, Eleventh Edition. Burlington, MA: Jones & Bartlett Learning; 2017. 2. Centers for Disease Control and Prevention. Pneumonia: an infection of the lungs. August 2017. https://www.cdc.gov/pneumonia. Accessed October 2017. 3. National Heart Lung and Blood Institute. Pneumonia: causes. September 2016. https://www.nhlbi.nih.gov/health/healthtopics/topics/pnu/causes. Accessed October 2017. Additional Resources Centers for Disease Control and Prevention. The Guidelines for Preventing Healthcare-Associated Pneumonia. 2003. https:// www.cdc.gov/infectioncontrol/guidelines/pdf/guidelines/ healthcare-associated-pneumonia.pdf.


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PREVENTION IN ACTION

FROM DATA TO DECISIONS

IUNEWIND/SHUTTERSTOCK.COM

Incidence versus prevalence BY DANIEL BRONSON-LOWE, PHD, CIC, FAPIC AND CHRISTINA BRONSON-LOWE, MS, CCC-SLP, CLD

WELCOME TO THE seventh installment in this series. This article

continues the discussion started in the previous issue about some uses of frequency measures in the field of infection prevention.

I

nfection preventionists use a variety of ratios, proportions, and rates. Many are types of incidence and prevalence. What does this mean? Consider a sink with water flowing in via the faucet and flowing out through the drain (Figure 1). The water represents the cases of interest, which can be infections, diseases, or any other event of interest, such as patient falls or adverse drug events. The sink represents the population at risk of becoming a case, such as the patients in a facility. The amount of

Figure 1

32 | WINTER 2017 | Prevention

water that has collected in the sink represents how much of that population is cases. This concept—the proportion of the population at risk that is cases at the moment when we collect the data—is the prevalence. The speed at which more water is being added

Figure 2

to the sink represents how quickly new cases are occurring in the population. This is the incidence. Finally, water can drain out of the sink. This represents cases being removed from the population at risk, for example due to cure, death, or transfer to another facility. Prevalence increases if incidence increases (Figure 2) or if the speed at which cases are removed decreases (Figure 3). So let’s dig into prevalence a bit. Prevalence quantifies the proportion of the population


that are cases at a given point in time and provides an estimate of the risk that someone will be a case at that point in time. This is the formula for calculating prevalence: number of EXISTING cases at a given point in time x 10n total population at risk (of which the numerator is a subset) at a given point in time The value 10n refers to 10 raised to the power n, such that:  100 = 1 (because anything raised to the power of 0 equals 1)  101 = 10 (because any value raised to the power of 1 is that same value)  102 = 10 x 10 = 100 ...and so on. There are actually two kinds of prevalence. They are calculated using the same equation, but they differ based on how data collection events are examined. If you include only the existing cases from a single instance of data collection, then you are calculating point prevalence. This means that the exact amount of time involved will be the smallest unit of time for which data are collected. For example, if data are collected every day, then the point prevalence will be based on the data from one day. That day could be a specific point in time on a calendar, like “February 12, 2017,” or a specific point in the course of events, like “Day 3 post-op.” On the other hand, if you include cases taken from a time period that covers data being collected multiple times— such as a month’s worth of daily data or a

year’s worth of monthly data—then you are calculating period prevalence. Incidence quantifies the number of new cases that develop in a population of individuals at risk during a specified time period. As with prevalence, there are two types of incidence: incidence proportion and incidence rate. The incidence proportion, also known as “cumulative incidence,” is a person-based calculation that incorporates the number of people at risk. It is the proportion of the total population at risk who can be newly counted as cases during the specified time period. In other words, they did not have the condition of interest when the time period began but developed it at any point during the time period. The formula for an incidence proportion is:

“Infection preventionists use a variety of ratios, proportions, and rates. Many are types of incidence and prevalence. What does this mean?”

number of NEW cases during a given time period x 10n total population at risk (of which the numerator is a subset) during that time period The incidence rate, also known as “incidence density,” is generally a more precise estimate of the impact of these events. This is because it incorporates the amount of time that each person was actually at risk rather than treating everyone as if they were at risk for the entire time period the way that incidence proportion does. The formula for an incidence rate is: number of NEW cases during a given time period total time at risk

x 10n

Figure 3

w w w.apic.org | 33


PREVENTION IN ACTION

34 | WINTER 2017 | Prevention

gmail.com.

Daniel Bronson-Lowe, PhD, CIC, FAPIC, has been an infection preventionist, an infectious disease epidemiologist, and a statistics lecturer. He has been an instructor for APIC’s “Basic Statistics for Infection Preventionists” Virtual Learning Lab and is a senior clinical manager with Baxter Healthcare Corporation. Christina Bronson-Lowe, MS, CCC-SLP, CLD, is a speech-language pathologist and PhD candidate who has worked in hospitals, inpatient and outpatient rehabilitation, SNFs, and home health care. Resources: Arias, KM. Chapter 11: Surveillance. In: Patti Grota, et al., editors. APIC Text Online. APIC; 2016. Arias, KM. Chapter 4: Surveillance. In: Monika Pogorzelska-Maziarz, et al., editors. Fundamental Statistics & Epidemiology in Infection Prevention. APIC; 2016. Potts, A. Chapter 13: Use of Statistics in Infection Prevention. In: Patti Grota, et al., editors. APIC Text Online. APIC; 2014. Potts, A. Chapter 2: Use of Statistics in Infection Prevention. In: Monika Pogorzelska-Maziarz, et al., editors. Fundamental Statistics & Epidemiology in Infection Prevention. APIC; 2016. Centers for Disease Control and Prevention. Principles of Epidemiology in Public Health Practice: An Introduction to Applied Epidemiology and Biostatistics, Third Edition. 2012. https://www.cdc.gov/ophss/ csels/dsepd/SS1978/SS1978.pdf

CONCEPT QUIZ AN INFECTION PREVENTIONIST (IP) collects daily data at her facility on the number of patients, numbers of catheter-associated urinary tract infections (CAUTIs), and use of urinary catheters. Her totals for the month are: • 800 patients • 2,000 patient-days • 75 indwelling urinary catheters • 380 urinary catheter-days • 5 existing CAUTIs • 10 new CAUTIs

Question 1 The IP decides to calculate the prevalence of CAUTIs for a one-month time period. Which of the following is true? A. This is will be the period prevalence because it uses daily data points collected for a month. B. The numerator must include the number of patients. C. The denominator must include the number of catheter-days. D. Prevalence cannot be calculated for a single month because the proportion of new CAUTIs to existing CAUTIs is unknown.

Question 2 The IP decides to calculate an incidence proportion for CAUTIs. What should be in the numerator? A. The number of new and existing CAUTIs B. The number of patients C. The number of new CAUTIs D. The population at risk

Question 3 Using the data provided by the scenario, calculate the incidence rate of CAUTIs during this month. Set 10n to 1000.

Answers 1. A 2. C 3. (10 new CAUTIs 380 ÷ urinary catheterdays) x 1000 = 26.3 CAUTIs per 1000 urinary catheter-days

In epidemiologic studies, the total time at risk tends to be in the form of personmonths or person-years, but in infection prevention it shows up as patient-days or device-days, like central line-days and urinary catheter-days. For instance, if during the time period of interest, Patient A had a central line for five days and Patient B had one for three days, the total time these patients were at risk for central line-associated bloodstream infections was eight person-days. There are a number of special types of incidence and prevalence, including morbidity rates, case-fatality rates, birth defect rates, and so on. The main difference between these measures and general incidence and prevalence calculations is usually that they focus on specific populations or events. For example, mortality rates are incidence proportions and are calculated using the incidence proportion formula. The only changes are that the “new cases” are deaths and the at-risk population is everyone at risk of dying. Attack rates—a measure used to represent the risk of acquiring a disease during an outbreak—are also incidence proportions. Different types of attack rates are generated based on how the at-risk population is defined for the denominator. If you have a norovirus outbreak in your facility, your initial at-risk population may

be everyone in the facility, so you might calculate an “overall attack rate” for your entire patient population. If the outbreak later appears to be linked to the food being delivered to patients, then you might narrow the at-risk population down to only individuals who ate certain foods, thereby calculating “food-specific attack rates.” When deciding which of these measures to use, keep the following in mind: • Prevalence: Shows what proportion of the population are cases at the time of interest. o Point Prevalence: Looks at the smallest unit of time feasible based on how the data in question were collected. o Period Prevalence: Looks at a period of time encompassing multiple data points. • Incidence: Shows how quickly new cases are occurring. o Incidence Proportion: Used when the at-risk measure in the denominator is a number of people. o Incidence Rate: Used when the atrisk measure in the denominator is an amount of person-time. If you have any questions or comments, please feel free to contact us at IPandEpi@


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PREVENTION IN ACTION

Focus on long-term care and behavioral health outbreaks: Identify the pathogen! BY STEVEN SCHWEON, RN, MPH, MSN, CIC, HEM, FSHEA, FAPIC

HOSPITAL OUTBREAKS ARE reported more often in the medical literature than occurrences in the long-term care (LTC) or behavioral health

setting. By studying and learning from outbreaks in the LTC/behavioral health setting, infection preventionists (IPs) will glean additional knowledge and apply this information to, hopefully, prevent future infections and infection clusters in their facility. This quarterly column will assist the IP with heightening awareness of appropriate interventions for preventing an outbreak.

I

n 2015, the Pinal County Public Health Services District in Arizona notified the Centers for Disease Control and Prevention (CDC) regarding a developmentally disabled, immunocompetent resident in an LTC facility.1 The resident had anemia and eosinophilia, a laboratory finding that indicates an elevated number of eosinophils, a condition seen in parasitic infections, allergic reactions, or cancer.2

As the IP, you suspect infection with: 1. Staphylococcus aureus, methicillin sensitive 2. Staphyloccus hominis, methicillin sensitive 3. Staphylococcus haemolyticus, methicillin sensitive 4. Strongyloides species The resident’s serum initially tested positive for Strongyloides stercoralis, an intestinal nematode (roundworm), and this was confirmed by the CDC. During a fivemonth period, 55 percent of the employees and all 91 residents were tested for strongyloides antibodies. None of the employees had positive specimens, while two

additional residents tested positive. All three residents were between 50-70 years old, two were female, and all had lived at the facility for more than 50 years. None of the residents had a rash; one had a chronic cough. Eosinophilia was documented 10-13 years before diagnosis. It was difficult to determine exactly when the eosinophilia began due to incomplete medical records. Two infected residents lived in the same house; the third resident had no close contact with the other two residents; none had a travel history. Obtaining a medical history and interview with the three residents was not possible

due to their developmental disabilities. The employees noted rectal digging, fecal smearing, and pica behaviors that reflect their developmental disability. The CDC investigators theorized these behaviors increased the transmission risk of ingesting stool-contaminated surfaces contaminated with Strongyloides larvae. In this population, hand hygiene was challenging after toilet use and at mealtime. The CDC notes strongyloidiasis is a disease caused by a roundworm, with over 40 species with a complex lifecycle, within the genus Strongyloides.3 The primary mode of infection is through contact with soil that is contaminated with the larvae, and these organisms have the ability to penetrate skin and migrate to the small intestine, where they are excreted in the stool. Strongyloides is commonly found in warm-moist climates, rural areas, or regions with agricultural activity. The majority of infected individuals are without symptoms. Others may complain of a rash, cough, abdominal pain, bloating, w w w.apic.org | 37


CDC/Dr. George R. Healy

PREVENTION IN ACTION

“Person-to-person transmission has also been reported in organ transplantation, long-term care facilities, and daycare centers”

Strongyloides stercoralis

TAKE HOME MESSAGES • Standard precautions are to be used when caring for infected individuals.7 Ensure safe procedures when disposing of bodily waste. • Strongyloides prevention interventions include an emphasis on hand hygiene and environmental hygiene. Shoes should be worn when walking on soil. • Strongyloides infection should be suspected in patients with chronic, unexplained eosinophilia. • There are no public health strategies for controlling the disease at a global level.4 • Seeking expert guidance from the public health department and other infectious diseases experts whenever an outbreak, or a possible outbreak, is occurring will augment operational, management, and control issues.

38 | WINTER 2017 | Prevention

heartburn, and intermittent diarrhea and constipation episodes. This organism can spread through the lymphatic system to the lungs. Severe infection, with potential mortality, can develop in immunocompromised individuals, e.g., hematologic malignancies, transplant recipients, and individuals who are taking steroids. Unless treated, the individual remains infected indefinitely. Infection can be diagnosed by visualizing the larvae during a microscopic stool examination or by testing the serum for antibodies or polymerase chain reaction.4,5 Person-to-person transmission has also been reported in organ transplantation, long-term care facilities, and daycare centers.3 Immigrant populations have the highest documented risk.3 In the United States, prevalence is probably underestimated due to the person’s potential lack of symptoms.6 While it’s uncommon there, rural areas of the southeastern states and Appalachia are at increased risk.6 An estimated 30-100 million individuals are infected worldwide.4 All three infected residents1 were treated with oral ivermectin, an anthelmintic agent and the treatment of choice.4 Eosinophil counts returned to normal in two of the residents who were tested; none of the residents had additional complications. The CDC team was not able to identify a source and noted that Arizona’s arid conditions decrease the likelihood this

nematode could be found. Additionally, the investigators felt the residents’ highrisk behaviors increased the likelihood of disease transmission through indoor and outdoor fecal contamination. Steven Schweon, RN, MPH, MSN, CIC, HEM, FSHEA, FAPIC, is an infection prevention consultant with a specialized interest in acute care/long-term care/behavioral health/ambulatory care infection challenges, including outbreaks. References 1. Jones JM, Hill C, Briggs G, et al. Notes from the field: Strongyloidiasis at a long-term care facility for the developmentally disabled-Arizona, 2015. MMWR Morb Mortal Wkly Rep 2016;65:608-609. www.cdc.gov/mmwr/volumes/65/ wr/mm6523a5.htm?s_cid=mm6523a5_e. Accessed June 2017. 2. Mayo Clinic. Eosinophilia. September 2016. www.mayoclinic.org/symptoms/eosinophilia/basics/definition/ sym-20050752. Accessed June 2017. 3. Centers for Disease Control and Prevention. Strongyloidiasis infection FAQs. www.cdc.gov/parasites/strongyloides/ gen_info/faqs.html. Accessed June 2017. 4. World Health Organization. Intestinal worms. Strongyloidiasis. www.who.int/intestinal_worms/epidemiology/strongyloidiasis/en/. Accessed June 2017. 5. Pearson RD. Strongyloidiasis. Merck Manual. February 2017. www.merckmanuals.com/professional/infectiousdiseases/nematodes-roundworms/strongyloidiasis. Accessed June 2017. 6. Chandreasekar PH. Strongyloidiasis. Medscape. November 2016. http://emedicine.medscape.com/article/229312overview. Accessed June 2017. 7. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https:// www.cdc.gov/infectioncontrol/pdf/guidelines/isolationguidelines.pdf. Accessed June 2017


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PREVENTION IN ACTION

Becoming an

APIC Fellow

BY LISA CAFFERY, MS, BSN, RN-BC, CIC, FAPIC

I

n May 2016, I was notified that I had been selected to be in the first class of APIC Fellows. It’s very humbling to see one’s name alongside the distinguished list of honorees, many of whom I have admired throughout my career. Being named a Fellow is an honor and a privilege, and it has challenged me to explore opportunities outside my comfort zone. Becoming a Fellow is not the end of the journey, but a step along the way.

Prior to submitting my application, I used the APIC Competency Self-Assessment and Professional Development Plan to assess my strengths and weaknesses.1 The tool helped me to focus on the areas needing to be strengthened, as well as create futureoriented career goals. The path to fellow status does not occur in isolation. Along the way I have had many mentors who have guided me throughout my nursing career. I could not have achieved this recognition without the support of my family and coworkers, who encouraged me to continue to learn and strive to be the best person possible. Early in my career in infection prevention, I became involved with Eastern Iowa APIC, my local chapter. I have since served in a variety of roles that have helped me to develop leadership skills and the confidence to volunteer at the national APIC level. Our chapter has had four members become APIC

Fellows in the first two classes. These Fellows have taken a leadership role in mentoring new infection preventionists (IPs), encouraging those preparing for certification, and assisting with statewide educational planning to ensure that IPs have the information they need to be successful. BECOMING AN APIC FELLOW

As I prepare to begin my term as chair of the Professional Development Committee (PDC), I want to share some information with you on the Fellows program and encourage you to consider applying for the recognition. Fellows have come from all practice settings, both in the United States and internationally. The program is designed to recognize IPs who have gone above and beyond to advance the profession. All IPs, regardless of their practice setting, are encouraged to apply if they meet the selection criteria.

Becoming a Fellow demonstrates a commitment to continued learning, mentorship, leadership, and research. It should also lead the Fellow to expand their knowledge base and continue to grow as a professional. Applying for Fellow recognition is easy, but it’s always good to plan ahead when the time comes. • It is important that you begin preparing your application early and download a practice application. The final application is online and must be completed in one sitting. • Confirm that your APIC membership and certification (CIC®) status are current. • Complete the APIC Competency SelfAssessment tool to determine where you are in your career development. • Update your CV/resume to ensure that it supports the activities listed in your application. Be sure to follow APA format when writing references. • Gather all the supporting documents in case there are questions about the activities listed on your application. NEW FOR 2018

There are two new criteria in 2018—all applicants must have a master’s degree or higher, and all activities must have occurred within the 10 years prior to applying. The criteria were developed around the four domains of the APIC Competency Model2: w w w.apic.org | 41


PREVENTION IN ACTION

• Leadership and Program Management • Infection Prevention and Control • Performance Improvement and Implementation Science • Technical You cannot use the same activity to meet the criteria for more than one domain; however, you can use the same delivery format (e.g., poster or oral presentation) for the activity. Please note that leadership activities must occur outside of your workplace responsibilities and you must be in a leadership role, such as a board director, committee chair, or co-chair. Some key items of the application to make note of are: • The publication/peer review requirement can make or break your application. Automatic publication like conference abstracts in AJIC (e.g., a supplement issue where ALL submissions are published) will not count. • Your five years of membership must be consecutive. • CIC certification is a requirement, not a preference. • Holding a master’s degree is a new requirement. Each application is reviewed by APIC staff and PDC leadership. Every effort is made to recognize all qualified applicants. If further supporting documentation is required, you

will be notified by APIC staff and asked to provide additional documents. Applicants who have been awarded Fellow status will be notified in May, and they will be recognized at the Annual Conference in June. You do not need to attend the Annual Conference, but I admit that it is pretty cool to see your name listed with your class and to wear the blue APIC Fellow ribbon on your conference name badge. You will also receive a certificate and, if you choose, a letter will be sent to your immediate supervisor. Lastly, there is some evidence that healthcare settings with IPs who are certified in infection control and prevention (CIC) demonstrate better patient outcomes.3,4 It will be interesting to see what impact a Fellow will have on patient care and outcomes in healthcare. It is important that leaders in healthcare settings recognize the skills and knowledge that an APIC Fellow brings to the table, whether the discussion is about infection prevention or patient safety. The skill set of an APIC Fellow can help to guide healthcare settings in the implementation of evidenced-based interventions to ensure that patients are receiving the best care possible. My challenge to you as we approach the new year is to complete the APIC SelfCompetency Assessment and, if the time

is right, consider submitting a Fellow application. You might be surprised at how much you have accomplished during your career! If this isn’t the right time, create your professional development plan and begin the steps to take your career to the next level. Lisa Caffery, MS, BSN, RN-BC, CIC, FAPIC, is the infection prevention coordinator at Genesis Health System in Davenport, Iowa. She is also the 2018 Chair of the APIC Professional Development Committee. References 1. Hanchett M. Self-assessment to advance IP competency. Prevention Strategist 2013;6(2):63-67. 2. Hanchett M. Moving the profession forward. Prevention Strategist 2012;5(2):46-51. 3. Pogorzelska M, Stone P, Larson E. Certification in infection control matters: Impact of infection control department characteristics and policies on rates of multidrug-resistant infections. Am J Infect Control 2012;40(2):96-101. 4. Kerin SL, Hofer TP, Kowalski CP, et al. Use of central venous catheter-related bloodstream infection prevention practices by US hospitals. Mayo Clin Proc 2007;82:672-678.

KEY APPLICATION INFO 1. Application opens: February 1, 2018 2. Application closes: March 31, 2018 3. A non-refundable $125 application fee is required For additional information, visit www.apic.org/fellows.

COMPETENCY SELF-ASSESSMENT AND PROFESSIONAL DEVELOPMENT PLAN FOR PROFICIENT AND ADVANCED INFECTION PREVENTIONISTS

Competency categories, integrating IP practice areas as identified in both the APIC and CBIC CBIC practice analysis domains

Identification of infectious disease processes (CBIC)

Describe how/ to what extent these areas are addressed in current IP role (or specify N/A)

Assessment of personal competency in each practice area

a. Interpret the relevance of diagnostic and laboratory reports

1

2

3

4

5

b. Identify appropriate practices for specimen collection, transportation, handling, and storage

1

2

3

4

5

c. C  orrelate clinical signs and symptoms with infectious disease process

1

2

3

4

5

d. Differentiate between colonization, infection, and contamination

1

2

3

4

5

e. D  ifferentiate between prophylactic, empiric, and therapeutic uses of antimicrobials

1

2

3

4

5

42 | WINTER 2017 | Prevention

Professional development plan to advance competency in the domain


Competency categories, integrating IP practice areas as identified in both the APIC and CBIC CBIC practice analysis domains Surveillance and epidemiologic investigation (CBIC) see more details on CBIC Examination Content Outline Future-oriented domain (APIC): Technical

Preventing/controlling the transmission of infectious agents (CBIC)

Preventing/controlling the transmission of infectious agents (CBIC), continued

Describe how/ to what extent these areas are addressed in current IP role (or specify N/A)

Assessment of personal competency in each practice area

a. Design of surveillance systems

1

2

3

4

5

b. Collection and compilation of surveillance data

1

2

3

4

5

c. Interpretation of surveillance data

1

2

3

4

5

d. Outbreak investigation

1

2

3

4

5

Example: electronic surveillance systems, access to/use of electronic databases/electronic data warehouse (EDW), other related applications, algorithmic detection and reporting processes, clinical decision support, infection prevention within the electronic health record

Professional development plan to advance competency in the domain

If no prior experience, ask:

How do I anticipate practicing in the next three to five years? What new knowledge/skills will be required?

a. D  evelop evidence-based/informed infection prevention and control policies and procedures

1

2

3

4

5

b. Collaborate with relevant groups in planning community/facility responses to biologic threats and disasters (e.g., public health, anthrax, influenza)

1

2

3

4

5

c. Identify and implement infection prevention and control strategies related to

1

2

3

4

5

• Hand hygiene

1

2

3

4

5

• Cleaning, disinfection, and sterilization

1

2

3

4

5

•W  herever healthcare is provided (e.g., patient care units, operating rooms, ambulatory care center, home health, pre-hospital care)

1

2

3

4

5

• Infection risks associated with therapeutic and diagnostic procedures and devices (e.g., dialysis, angiography, bronchoscopy, endoscopy, intravascular devices, urinary drainage catheter)

1

2

3

4

5

•R  ecall of potentially contaminated equipment, food, medications, and supplies

1

2

3

4

5

• Transmission-based precautions

1

2

3

4

5

•A  ppropriate selection, use, and disposal of personal protective equipment

1

2

3

4

5

• Patient placement, transfer, discharge

1

2

3

4

5

•E  nvironmental pathogens (e.g., Legionella, Aspergillus)

1 2 3 4 5

•U  se of patient care products and medical equipment

1

2

3

4

5

• Immunization programs for patients

1

2

3

4

5

• Influx of patients with communicable diseases

1

2

3

4

5

• Principles of safe injection practices

1

2

3

4

5

• Identifying, implementing and evaluating elements of standard precautions/routine practices

1

2

3

4

5

• Antimicrobial stewardship

1

2

3

4

5

w w w.apic.org | 43


PREVENTION IN ACTION

Competency categories, integrating IP practice areas as identified in both the APIC and CBIC CBIC practice analysis domains

Future-oriented domain (APIC): Infection prevention and control

Management and communication (CBIC) see more details on CBIC Examination Content Outline

Future-oriented domain (APIC): Leadership and program management

Education and research (CBIC) see more details on CBIC Examination Content Outline

Future-oriented domain (APIC): Performance improvement and implementation science

Examples: ability to apply and use surveillance data and reports, advanced statistical methods and tools, including application of the standard infection ratio, risk assessment, hazard vulnerability analysis, use and evaluation of emerging prevention practices for patient care, diagnostic methods, participation in antimicrobial stewardship programs

Describe how/ to what extent these areas are addressed in current IP role (or specify N/A)

Assessment of personal competency in each practice area

If no prior experience, ask: How do I anticipate practicing in the next three to five years? What new knowledge/skills will be required?

a. Planning

1

2

3

4

5

b. Communication and feedback

1

2

3

4

5

c. Q  uality/performance improvement and patient safety

1

2

3

4

5

Examples: leads integration of prevention activities within and across departments, high level negotiation skills, financial/value analysis of programs and related projects, relationship management, ability to influence and persuade up to and including executive level, team and consensus building within and across stakeholder groups

If no prior experience, ask: How do I anticipate practicing in the next three to five years? What new knowledge/skills will be required?

a. Education

1

2

3

4

5

b. Research

1

2

3

4

5

Examples: leads performance improvement (PI) teams for institution/system, develops interprofessional competencies, applies translational research methods, uses advanced PI tools/methods, focus on reliability and sustainability

44 | WINTER 2017 | Prevention

Professional development plan to advance competency in the domain

If no prior experience, ask: How do I anticipate practicing in the next three to five years? What new knowledge/skills will be required?


Competency categories, integrating IP practice areas as identified in both the APIC and CBIC CBIC practice analysis domains

Employee/occupational health (CBIC)

Environment of care (CBIC)

Cleaning, sterilization, disinfection, asepsis (CBIC)

Describe how/ to what extent these areas are addressed in current IP role (or specify N/A)

Assessment of personal competency in each practice area

a. R  eview and/or develop screening and immunization programs

1

2

3

4

5

b. Collaborate regarding counseling, follow up, and work restriction recommendations related to communicable diseases and/or exposures

1

2

3

4

5

c. C  ollaborate with occupational health to evaluate infection prevention-related data and provide recommendations

1

2

3

4

5

d. Collaborate with occupational health to recognize healthcare personnel who represent a transmission risk to patients, coworkers, and communities

1

2

3

4

5

e. A  ssess risk of occupational exposure to infectious diseases (e.g., Mycobacterium tuberculosis, bloodborne pathogens)

1

2

3

4

5

a. R  ecognize and monitor elements important for a safe care environment (e.g., heating-ventilationair conditioning, water standards, construction)

1

2

3

4

5

b. Assess infection risks of design, construction, and renovation that impact patient care settings

1 2 3 4 5

c. P  rovide recommendations to reduce the risk of infection as part of the design, construction, and renovation process

1

2

3

4

5

d. Collaborate on the evaluation and monitoring of environmental cleaning and disinfection practices and technologies

1

2

3

4

5

e. C  ollaborate with others to select and evaluate environmental disinfectant products

1

2

3

4

5

a. Identify and evaluate appropriate cleaning, sterilization and disinfection practices

1

2

3

4

5

b. Collaborate with others to assess products under evaluation for their ability to be reprocessed

1

2

3

4

5

c. Identify and evaluate critical steps of cleaning, high-level disinfection, and sterilization

1

2

3

4

5

Professional development plan to advance competency in the domain

Updated August 2017 to align with changes in CBIC Examination Content Outline (2017)

ASSUMPTIONS:

• Once certification in infection control (CIC) has been achieved, competency is highly individualized and technically complex. It is driven by multiple factors, including educational opportunities, practice setting, and personal interests. Because competency is highly personalized and develops across the career span, no infection preventionist (IP) is expected to be “advanced” in most/all areas at any particular time. The goal is to identify areas for individual improvement so that professional development becomes a lifelong endeavor. • The core competencies identified by CBIC and the future-oriented domains added by APIC are complementary and not mutually exclusive categories. By integrating them into one comprehensive self-assessment, the IP will be better prepared to address both immediate and evolving professional demands. • Core competencies as identified by CBIC remain relevant across the career span, but their implementation evolves as proficiency increases. Therefore, assessment of core competencies for proficient and advanced IPs focuses on how these skills are applied and the extent to which the IP is able to utilize them to foster program development and to assist others in their prevention efforts. • The future-oriented domains described by APIC build on the core competencies. The content may at times appear to overlap. However, the future-oriented domains attempt to identify those skills not yet included in the CBIC practice analysis but which, based on observation and professional consensus, are expected to be essential for IP practice in the next three to five years.

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PREVENTION IN ACTION

CMS mandates water management programs PHOTO CREDIT: MATTHEW HYATT/SHUTTERSTOCK.COM

in healthcare facilities

BY MAY MEI-SHENG RILEY, MSN, MPH, RN, ACNP, CCRN, CIC, FAPIC, AND ANNEMARIE FLOOD, MPH, BSN, RN, CIC, FAPIC

BACKGROUND

A study conducted by Tufts University School of Medicine found that more than 617,000 hospitalizations from 1991 to 2006 were related to three common opportunistic waterborne pathogens: Legionella pneumophila, Mycobacterium avium, and Pseudomonas aeruginosa.1 These hospitalizations resulted in costs of about $9 billion in Medicare payments—an average of $600 million a year. The costs may now exceed $2 billion for 80,000 cases per year.1 Between 2000 to 2014, there was a four-fold increase in the number of cases of Legionnaires’ disease.2 According to the Centers for Disease Control and Prevention (CDC), 85 percent of all Legionnaires’ disease outbreaks were attributed to water system exposures that could have been prevented by effective water management programs (WMP).3 Therefore, it is essential that healthcare facilities establish WMPs to ensure water safety for patients. 46 | WINTER 2017 | Prevention

LEGIONELLA AND OTHER WATERBORNE PATHOGENS

Legionnaires’ disease is a severe pneumonia caused by Legionella, a waterborne bacterium. Legionella species are gram-negative bacilli, measuring 2 to 20μm, found naturally in freshwater environments.4 Legionella is of concern when it grows and spreads in water systems, such as showers, faucets, cooling towers, decorative fountains, and hot tubs that are not drained after each use. It can flourish in complex building water systems that are not well maintained. The following conditions promote Legionella growth3,5: • L ow level of disinfectant: Inadequate disinfection cannot kill or inactivate Legionella species. •  Stagnation: Allows biofilm growth, reducing the effectiveness of disinfection and providing protection from heat. • Biofilm: Provides food and shelter to waterborne organisms.

• Sediment: Promotes growth of water commensal microflora. • Algae, flavobacteria, and Pseudomonas can supply nutrients for Legionella growth. • Temperature between 20 and 50°C (68– 122°F) (optimal growth temperature range is 35–46°C [95–115°F]). • pH between 5.0 and 8.5. Those most susceptible to the disease are people age 50 or over; those with a history of smoking, chronic disease, immunosuppression, or cancer; or people with underlying illnesses such as diabetes, kidney failure, or liver failure. While about 10 percent of cases are fatal, mortality associated with healthcare-associated Legionnaires’ disease is reported to be as high as 46 percent.3 Besides Legionella species, there are many opportunistic waterborne pathogens, such as Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi.6 Effective WMPs not only reduce the risk of Legionella growth, but also prevent growth of other waterborne pathogens.


CMS REGULATORY AUTHORITIES

On June 2, 2017, the Centers for Medicare & Medicaid Services (CMS) released a policy memorandum (Ref: S&C 17-30-Hospitals/ CAHs/NHs) mandating WMPs in all healthcare facilities to reduce Legionella risk.6 This memorandum is addressed to hospitals, critical access hospitals, and long-term care facilities. However, all healthcare organizations need be aware of the issue. Healthcare facilities are expected to: • Conduct a facility-wide water safety risk assessment. • Implement a WMP based on the ASHRAE standard 188 and CDC kit.7-8 • Define and specify testing protocols, acceptable ranges for control measures, and document specific actions that will be taken when control limits are not met. The optimal goal is to mitigate the risk of growth and spread of Legionella and other opportunistic waterborne pathogens in healthcare facility water systems. Healthcare facilities are expected to comply with these requirements to protect their patients. Facilities failing to demonstrate measures to minimize the risk of Legionnaires’ disease risk citation for noncompliance with the CMS Conditions of Participation.

Figure 1.

WHAT HEALTHCARE FACILITY LEADERS NEED TO KNOW

This CMS regulatory memorandum (Figure 1) is mandatory. Healthcare facility leadership needs to know that this memorandum is pertinent to the (previously published) 42 CFR §482.42 for hospitals6: The hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases. Noncompliance may carry severe consequences (e.g., losing CMS reimbursement or a CMS citation). In response, healthcare facilities should create WMPs and ensure that the following elements of water management are implemented7-8: 1.  Establish a water management program team to comply with ASHRAE standard 188 and CDC kit. 2. Describe building water systems using text and flow diagrams.

3. Identify at-risk populations. 4. Identify areas, equipment, and systems at risk where Legionella could grow and spread. 5. Assign responsibility to implement risk mitigating strategies. 6. Establish actions to monitor the strategy parameters. 7. Decide where control measures should be applied and how to monitor them. 8. Establish interventions when control limits are not met. 9. Communicate throughout the facility.

0. Document all the activities. 1 11. Ensure the program is running as designed and is effective by reviewing the program periodically. 12. Keep accurate records. Water disinfection falls mainly under each facility’s department of maintenance and engineering as these staff members have knowledge of the plumbing system design and current operation. They know water treatment and proper procedures for a controlled shutdown and water disruption.7-9 w w w.apic.org | 47


PREVENTION IN ACTION

The Joint Commission Leadership Standard (LD.01.03.01) states, “The governing body is ultimately accountable for the safety and quality of care, treatment, and services.” Healthcare executives must provide leadership support and financial support to ensure that WMPs are established and operate effectively. WHAT IPS NEED TO KNOW

IPs play a critical role in WMP teams. IPs are the subject matter experts in waterborne pathogen transmission routes, infection prevention protocol, and methods of preventing infection. IPs know where high-risk patient populations are located, including inpatient and outpatient care areas. IPs can identify clinical support areas and components and devices that can expose patents to contaminated water. Therefore, IPs are essential members of water management committees.7-8 The CDC toolkit for reducing Legionella growth has guides and includes a specific section for healthcare facilities.8 The toolkit can steer IPs in their practice. IPs should collaborate with the other departments to implement the following actions in the WMP.

READ MORE ABOUT WATERBORNE PATHOGENS IN THE AMERICAN JOURNAL OF INFECTION CONTROL Water Management Program Implementation at a New Children’s Hospital: Using a Process to Prevent Waterborne Pathogen Disease. Rupp A, Cain MF, Cochran M, American Journal of Infection Control, Vol. 43, Issue 6, S53. Evaluation of a New Point-of-use Faucet Filter for Preventing Legionella and Total Bacterial Exposure. Baron J, Peters T, Shafer R, et al., American Journal of Infection Control, Vol. 42, Issue 6, S146. Collateral Damage in the Battle Against Legionella: Effects of Chlorine Dioxide on a Dialysis Unit Water System. Sisler L, Gotses J, Smith R, American Journal of Infection Control, Vol. 45, Issue 6, S36–S37.

48 | WINTER 2017 | Prevention

1. Conduct risk assessment for waterborne pathogens. 2. Identify location of reservoirs (wet sites) and disseminators.10 Some examples: a.  Humidifiers, ventilators, CPAP machines, hydrotherapy equipment, sinks, hot tubs (saunas), fountains, aerators, faucet flow restrictors, ice machines. b.  Wet mops, wet sponges, wet washcloths. 3. Assess likelihood of aerosol exposure and likelihood of bacterial growth. 4. Identify high-risk patient population units and locations. 5. Evaluate the necessity of installing point-of-use water filtration to protect highly susceptible populations. 6. Establish proactive action plans to be taken to eliminate risk. 7. Perform surveillance for waterborne disease among patients. 8. If a case is identified, notify the state department of public health and healthcare providers, so clinicians can test patients with healthcare-associated pneumonia for Legionnaires’ disease with both a culture of respiratory secretions and the Legionella urinary antigen test. 9. Conduct investigations. 10. Prepare contingency plans in the event of water restriction. 11. Communicate throughout the facility and document the activities. Healthcare-associated waterborne illnesses present a significant risk to patients. An effective comprehensive water management program can have a positive impact on patients and quality of care.11 WHAT’S COMING NEXT?

On August 18, 2017, the CDC announced the opening of a docket to obtain public comments on effective methods for achieving implementation and how WMPs can be improved.12 The information will be used to guide best practices in preventing Legionnaires’ disease and disease due to other waterborne pathogens. The CDC will update its guidelines and recommendations to reflect the information gathered. It is of paramount importance that IPs stay alert for updates on WMPs

from the CDC and their state public health authorities. May Mei-Sheng Riley, MSN, MPH, RN, ACNP, CCRN, CIC, FAPIC, is an infection control consultant at Stanford Health Care. She is a member of the Prevention Strategist Editorial Panel, and also serves as a secretary on the California APIC Board of Directors. Annemarie Flood, MPH, BSN, RN, CIC, FAPIC, is the senior manager for the Infection Prevention Program at City of Hope in Duarte, California and also serves on APIC’s Board of Directors. REFERENCES 1. Naumova EN, Liss A, Jagai JS, et al. Hospitalizations due to selected infections caused by opportunistic premise plumbing pathogens (OPPP) and reported drug resistance in the United States older adult population in 1991–2006. J Public Health Pol. 2016;37(4): 500-513. https://link.springer.com/article/10.1057/s41271016-0038-8. Accessed September 2017. 2. Centers for Disease Control and Prevention. Legionella (Legionnaires’ Disease and Pontiac Fever). Updated June 2017. https://www. cdc.gov/Legionella/surv-reporting.html. Accessed September 2017. 3. Soda EA, Barskey AE, Shah PP, et al. Vital Signs: Health Care– Associated Legionnaires’ Disease Surveillance Data from 20 States and a Large Metropolitan Area — United States, 2015. MMWR Morb Mortal Wkly Rep. 2017;66(22):584-589. 4. Murray PR, Rosenthal KS, Pfaller MA. Miscellaneous gram-negative rods. In: Murray PR, ed. Medical Microbiology. 8th ed. New York, NY: Elsevier Inc; 2016. p. 287-300. 5. United States Department of Labor. Occupational Safety and Health Administration. Legionnaires’ Disease. In: OSHA Technical Manual, 1991. https://www.osha.gov/dts/osta/otm/otm_iii/ otm_iii_7.html. September 2017. 6. Centers for Medicare & Medicaid Services. Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease. June 2017. https://www.cms.gov/Medicare/Provider-Enrollmentand-Certification/SurveyCertificationGenInfo/Downloads/ Survey-and-Cert-Letter-17-30.pdf. Accessed September 2017. 7. ASHRAE Standard 188-2015. Legionellosis: Risk Management for Building Water Systems. Atlanta, GA: ASHRAE; 2015. https:// www.techstreet.com/ashrae/standards/ashrae-1882015?product_id=1897561. Accessed September 2017. 8. Centers for Disease Control and Prevention. Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings, June 2016. https://www.cdc.gov/Legionella/ maintenance/wmp-toolkit.html. Accessed September 2017. 9. Sehulster L, Chinn RY, CDC, HICPAC. Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep 2003;52(RR-10):1-42. https:// www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm. Accessed September 2017. 10. E xner M, Kramer A, Lajoie L, et al. Prevention and control of health care-associated waterborne infections in health care facilities. Am J Infect Control 2005;33(5):S26-40. 11. Larson E, Aiello A. Systematic risk assessment methods for the infection control professional. Am J Infect Control 2006;34(5):323-326. 12. Centers for Disease Control and Prevention, Department of Health and Human Services. Effective Methods for Implementing Water Management Programs (WMPs) To Reduce Growth of Transmission of Legionella spp. Federal Register 2017;82(159). https://www.gpo.gov/fdsys/pkg/FR-2017-08-18/pdf/201717491.pdf. Accessed September 2017.


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PREVENTION IN ACTION

In pursuit of a fair and just culture: An application of key components in infection prevention BY SAVANNA STOUT, MPH, MBA, CPHQ, CPPS

T

he National Patient Safety Foundation (NPSF) defines a safety culture as “one in which healthcare professionals and leaders are held accountable for unprofessional conduct, yet not punished for human mistakes; errors are identified and mitigated before they harm patients; and strong feedback loops enable frontline staff to learn from previous errors and alter care processes to prevent recurrences.”1 For most facilities, successfully implementing a safety culture has required a strong leadership commitment to change how individuals respond to undesired outcomes; specifically, moving away from reactive responses and expecting perfection, to reframing how healthcare providers prevent, mitigate, and react to situations and events that are undesirable. Organizations have been able to invoke meaningful cultural change that promotes safety culture by adopting fair and just culture models. The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network defines a fair and just culture as one that “focuses on identifying and addressing systems issues that lead individuals to engage in unsafe behaviors, while maintaining individual accountability by establishing zero tolerance for reckless behavior. It distinguishes between human error (e.g., slips), at-risk behavior (e.g., taking shortcuts), and reckless behavior (e.g., ignoring required safety steps), in contrast to an overarching ‘no-blame’ approach.”2 Furthermore, the concept of a fair and 50 | WINTER 2017 | Prevention

just culture is not a new one and can be found dotted throughout other industries, like aviation.3 However, it wasn’t until the early 2000s that fair and just culture models created specifically for healthcare emerged. Of note, the United Kingdom created the National Patient Safety Agency (NPSA) in 2001. One of its main purposes was to develop a means to prompt safety culture within the country’s national healthcare system. Subsequently, as they worked to install a safety culture, a model for fair and just culture was also developed to assist with the implementation.4 Another fair and just culture pioneer emerged that same year, when David Marx penned Patient Safety and the “Just Culture”:

A Primer for Health Care Executives. Similar to NPSA’s model, Marx’s model focused on evaluating human behaviors and their impact on unwanted incidences.5 As Marx continued his work in the fair and just culture realm, he revised and expanded his model by adding additional elements, including an algorithm to further simplify the model’s application. His updated framework evolved into what is known as Outcome Engenuity’s (formerly Outcome Engineering) fair and just culture model, and today is widely known within the healthcare field. OUTCOME ENGENUITY MODEL

Outcome Engenuity’s (OE) model has three main components: behaviors, duties, and skills. Together, these main components provide a consistent method for evaluating behavior choices that resulted in unwanted outcomes (breaches in duties) in light of an organization that had approaches (skills) in place to aid in producing better outcomes. 6 A thorough understanding of OE’s model takes a significant amount of training. However, in brief, it’s possible to glean


deadline is more important. While this is an extreme scenario, it demonstrates a conscious disregard for substantial and unjustifiable risk, in other words—true negligent actions. Thinking of behaviors systematically demonstrates that not all behaviors involved in negative outcomes can be dealt with in the same manner. Nor can they be handled by using old thinking styles of “no harm no foul,” or the knee-jerk response of “punish everyone involved.”

©ISTOCKPHOTO.COM/GERENME

THREE DUTIES

knowledge of the model by examining its three components. THREE BEHAVIORS

The first component of OE’s model clearly defines behavior choices that impact outcomes. Human error—inadvertently doing other than what should have been done: a slip, lapse, or mistake.7 A common example of human error is forgetting and/or inadvertently making a mistake, such as when a patient is admitted to a medical unit and is initially isolated for methicillin-resistant Staphylococcus aureus (MRSA), but the bacteria the patient had was actually methicillinsusceptible Staphylococcus aureus (MSSA); the nurse misheard the report at handoff. At-risk behavior—behavioral choice that increases the risk where risk is not recognized, or is mistakenly believed to be justified.7 Many times, at-risk behaviors are associated with work-arounds such as skipping a step in a process either because staff have a misplaced level of risk associated with the step, or skipping the step has saved them

time and there has never been an immediate consequence. Furthermore, at-risk behavior may also result from the notion that “we’ve always done it this way and nothing bad has ever happened.’’ At-risk behavior is considered the greatest threat to organizations since it’s typically “invisible” to leadership and not identified until an actual unwanted event occurs. An example of this would be when a nurse does not scrub a connector hub for at least 15 seconds before attaching a syringe, believing the minimal wipe he completed is enough since he can see the hub appears visibly clean. Reckless behavior—a conscious disregard of a substantial and unjustifiable risk of causing harm…[and should be something] absolutely avoid[ed].7 This last behavior is infrequent, but an example would be if a construction project manager who’s been educated on the infection prevention requirements for demolition decides to allow heavy demolition to start in one of the NICU rooms before any barriers are up, air cleaners are in place, and negative pressure has been achieved because she believes meeting her

The second component of OE’s fair and just culture relates to three duties applicable to all organizations. The duty to avoid unjustifiable risk or harm. OE defines this as the highest duty. This is not just something an employer wants from an employee, but rather something society would require, i.e., don’t commit murder. 7 The duty to follow a procedural rule. This duty applies to situations where an employer provides a prescriptive procedure or process for achieving an outcome and the employee is expected to follow it. In this situation, the employer is looking to the employee to be a reliable component in the process or procedure.7 The last duty is the duty to produce an outcome. This applies when an employee is in control of producing a certain outcome for an employer and it is up to the employee to determine how to get to the outcome.7 FIVE SKILLS

With the other two components outlined, it’s possible to look at the final component of OE’s fair and just culture model—skills. Skills are used to help organizations better achieve their desired outcomes and fully incorporate the fair and just culture model. Values and expectations are the first skill of the OE model. This can be thought of as an organization’s commitment to safety culture. The thought here is that perfection is not expected, but rather each staff member does their part to achieve desired outcomes, including speaking and reporting when things are not right. Basically this encompasses setting clear expectations for staff, which are built from the organization’s values and mission to achieve a safety culture. The second skill in the OE model is managing system design. This is the concept that organizations design systems that are w w w.apic.org | 51


PREVENTION IN ACTION

built to prevent errors and/or are error tolerant, meaning they have barriers in place to capture errors before they occur or get to a downstream point where they have the potential to cause harm. Third is management of behavioral choices, which relates to having the appropriate response for when different types of behavioral choices occur. In instances when human error occurs, staff would be consoled and leaders will look to the design of systems for failures and opportunities. In instances of at-risk behavior, staff would be coached so that they understand the risk associated with their choices. In those extreme circumstance where reckless behavior occurs, leaders have the right to consider punitive response. The fourth skill of the OE model is ensuring learning systems are vital facets within an organization. This means using mistakes, unwanted outcomes, and near misses as opportunities to learn, share learnings with others, and see if the system design can be improved. Finally, the fifth skill is creating an environment of justice and accountability. The environment of justice and accountability brings all the pieces of the OE model full circle, where organizations foster an environment of “fairness and consistency” when investigating, analyzing, and taking action on events and occurrences, regardless of who was involved or the severity of the outcome. This also includes staff being accountable for their actions.6,7 To help organizations ensure they are fostering such an environment, the OE model incorporates a valuable tool—an algorithm. This provides a systematic method for occurrence evaluation and should be used with each and every incident. IMPLEMENTATION

With the OE model laid out, it’s clear that the methodology is robust, and a fullscale implementation must be supported, started, and carried through by leadership for it to reach all parts of a facility; it takes time to successfully implement a fair and just culture. This doesn’t mean certain elements of the model can’t be realized and executed at the department level, specifically within infection prevention and control, while an organization rolls out a house-wide implementation. Departments may want to use the following as general guidance to 52 | WINTER 2017 | Prevention

“Organizations have been able to invoke meaningful cultural change that promotes safety culture by adopting fair and just culture models.” determine which elements of the model they can implement: SKILLS COMPONENT

• Have departmental values and expectations for house-wide infection prevention matters where the expectation for patient care staff is not that they achieve perfection with certain tasks, but that they make the attempt to be “reliable components.” • Evaluate systems designed by infection prevention to determine if there are mechanisms, redundancies, and barriers in place to catch errors before they occur or have further downstream impact. An example would be point-of-entry screening that prompts patient care staff to place patient in isolation should they have risk factors for certain communicable diseases. • C omplete thorough investigations to understand why process/procedures didn’t go as planned, determining if there were any lessons to be learned, and then sharing those lessons with others. • Promote open reporting and question asking from staff about infection prevention-related topics they feel present risk, without fear of punishment for reporting or retribution from peers. BEHAVIOR/DUTY COMPONENT

• Identify behavior choices that may have resulted in an unwanted infection prevention incident. If human error occurred, console staff and determine if there are any needed changes to the design of the system so that staff doesn’t make these errors in the future. If at-risk behavior occurs, coach staff so they understand why their behavior choice is actually risky and provide evidence to support the risk. If truly reckless behavior is identified, make sure to follow the chain of command and elevate to appropriate leaders. • Determine if there are breaches in duties when infection prevention events occur. Start by verifying if staff were aware of the

“duty,” such as would be the case in the duty to follow a procedural rule. Evaluate if there were any legitimate reasons the breaches occurred, or if additional action needs to be taken by the infection prevention department to discourage breaches. Almost 20 years after the Institute of Medicine released To Err is Human, it is no surprise that most healthcare professionals are well aware of the relationship between quality of care and patient safety. Over the last two decades, patient safety concepts and approaches have expanded exponentially as healthcare organizations continue to pursue an engrained, highly functional safety culture. In the patient safety-centered healthcare world of today, it takes all hands on deck to ensure quality of care and patient safety. Part of that means a total culture change, and many organizations look to do this by implementing a fair and just culture model. While an organizational transition takes time, it’s possible to start small at the department level and ultimately create better outcomes. Savanna Stout, MPH, MBA, CPHQ, CPPS, is an infection preventionist at Northwestern Medicine Central DuPage Hospital in Illinois. She received her Just Culture certification from Outcome Engenuity and has worked in inpatient quality improvement. References: 1. National Patient Safety Foundation. Free From Harm Accelerating Patient Safety Improvements 15 Year after To Err is Human. 2015. http://c.ymcdn.com/sites/www.npsf.org/resource/ resmgr/PDF/Free_from_Harm.pdf. Accessed September 2017. 2. Agency for Healthcare Research and Quality Patient Safety Network. Patient Safety Primer. Culture of Safety. June 2017. https://psnet.ahrq.gov/primers/primer/5/safety-culture. Accessed September 2017. 3. Agency for Healthcare Research and Quality Patient Safety Network. Perspectives on Safety. In Conversation with…David Marx, JD. October 2007. https://psnet.ahrq.gov/perspectives/ perspective/49/in-conversation-with-david-marx-jd. Accessed September 2017. 4. National Patient Safety Agency. The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents. March 2005. https://www.ahrq.gov/downloads/pub/advances/ vol4/meadows.pdf. Accessed September 2017. 5. Marx D. Patient Safety and the “Just Culture”: A Primer for Health Care Executives. April 2001. http://www.chpso.org/sites/ main/files/file-attachments/marx_primer.pdf. Accessed September 2017. 6. Outcome Engenuity. What does a model of accountability look like? https://www.outcome-eng.com/getting-to-knowjust-culture/. Accessed September 2017. 7. Outcome Engineering. Just Culture Training for Healthcare Managers. Texas[United States]: Outcome Engineering, LLC; 2008.


FEATURE

Getting from the starting point to the finish line:

Project management skills for IPs BY KELLEY BOSTON, MPH, CIC, CPHQ, FAPIC

54 | WINTER 2017 | Prevention


©ISTOCKPHOTO.COM/CECILIE_ARCURS

H

ealthcare-associated infections (HAIs) are a significant public health threat, impacting one out of every 25 hospital patients, and have a significant financial impact through increased costs of care and treatment and risk to federal reimbursement through value-based purchasing.1 Healthcare organizations are increasingly focused on the reduction and elimination of infections, and infection preventionists (IPs) are often challenged by their organizational leadership to “fix the HAI problem.”

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PROJECT MANAGEMENT SKILLS FOR IPS

APIC’s long-term vision is healthcare without infection, but meeting this is not a simple problem to solve.2 To be effective in changing care and improving patient outcomes, IPs need to understand the epidemiology of infection, patient care practices, organizational culture, performance improvement, and change management strategies. We need to be able to identify and understand the processes that drive infection risk, influence changes in systems and behaviors that increase potential for infection, and promote adoption of those that decrease infection risk. For most HAIs, the IP is not directly involved in the processes of patient care and cannot succeed in changing them alone. We must build a team of partners and collaborators, and work together with a group of people, each using their unique skills to move us forward to our common goal. PROJECT MANAGEMENT BASICS

Project management skills are central to completing the work of prevention, and are addressed in the APIC Professional and Practice Standards under the performance improvement category.3 A project is a shortterm, temporary set of work, with a defined beginning and end point that is undertaken in order to achieve a particular result or goal. It is not a routine operation, but is one stepping stone along the route toward a longerterm goal or vision. Projects are constrained in scope, time, and resources, and are generally limited to solving specific problems.4 Project management is frequently broken down into five process areas4: Initiating: identify goal or task to be accomplished by the project, assess feasibility, and decide whether to proceed.  Planning: define the scope of the project, potential risks, activities that will occur, deliverables at completion, and parameters for timeline, cost, resources needed, and quality required; assign responsibility for project tasks and activities; gain final approval for project. E xecuting: launch project and complete project tasks and activities.  Monitoring and Controlling: compare actual progress and performance on project activities to planned

1 2

3 4 56 | WINTER 2017 | Prevention

performance on goals, budget, and timelines; implement corrective actions as needed; communicate progress, successes, and barriers.  Completion and Closing: complete final project activities, identify outstanding tasks and develop a plan for completion, review what went well and any failures; prepare a final report summarizing project actions and measurement against estimated budget, timelines, and goals. These phases closely parallel the DMAIC (define, measure, analyze, improve, control) performance improvement framework that many IPs and healthcare quality professionals regularly utilize for performance improvement and change management.5 IPs are frequently leaders on performance improvement or other projects that focus on patient safety and reducing the risk of infection. Project management skills, paired with performance improvement and change management skills, can help IPs be more successful in driving changes in care practices and behavior that impact patient outcomes.

5

CRITICAL LEADERSHIP SKILLS FOR EFFECTIVE PROJECT MANAGEMENT

Successful project management, much like successful leadership, is all about people. As a project leader, the IP must be able to build relationships and partnerships with project stakeholders and team members. The IP must lead through influence to ensure completion of the project. IPs build partnerships to work with healthcare teams to move organizations closer and closer toward our vision of healthcare without infection.

Listening

Project leadership begins with listening. A project often arises based on business needs or desires; the project leader must seek to understand the strategic goals of the organization, the current processes that are in place which are driving outcomes, and the desired state after project completion. The project leader must assess the needs of all customers, which include both those requesting the change and those who will be impacted by it. This involves identification of all those who have a stake in the project or will be


impacted by it, and careful listening to understand their needs and what is most valued to each group. It is important to include input and feedback from the front-line staff that are closest to the process and have the best understanding of what is truly happening, and the impact the project activities have on their work flow. Seeking this input will also help the IP project leader assess the group’s readiness to make changes, participate in project work, and identify potential hidden barriers. When barriers are identified, take the opportunity to engage in shared problem solving to find solutions.

Communication

The IP project leader must be a strong and open communicator who can clearly express the work of the project and how it fits into the organization’s strategic goals, and moves toward the larger vision of elimination of infection. They must be able to communicate goals, responsibilities and expectations, and provide effective positive and negative feedback. They should understand the need for different communication styles and formats for different groups, and the impact of messaging from different sources. In negotiations, they should seek to create and capture value, and to find solutions that come as close as possible to meeting the needs of all parties.

Prioritization and delegation

There is only so much that each individual or team can realistically accomplish at one time. The project leader must be able to identify which activities will have the largest impact on outcomes or are key to project success or timelines; consider how those activities are aligned with the project’s and the organization’s goals; and must help the team prioritize work toward those areas. Prioritization makes best use of the team’s limited time and creates space to handle unexpected problems or interruptions. As the activities of the project are defined, tasks and responsibilities are assigned to project team members for completion. Decisions must be made about which individuals are responsible for individual work activities, who is accountable for ensuring completion, and who needs to be consulted or informed about activity—the RACI (responsible, accountable, consulted, and informed) responsibility assignment matrix is a useful tool for these decisions. Division of team work activities and delegation to those individuals who have the appropriate skills or resources creates group ownership in achieving targets. Assigning responsibility and empowering team members to complete tasks and make decisions shows trust in your team, and creates a learning community within the team where individuals have the opportunity for personal growth and development.

Enthusiasm

Projects can be difficult for teams and leaders to complete. Having energy, excitement, and enjoyment for the project helps carry the team through difficult moments, and inspires them to work through barriers and challenges. A leader’s enthusiasm can help the team sustain momentum. Enthusiasm must be genuine;

KEY COMPONENTS FOR PROJECT MANAGEMENT PHASES INITIATING • Understanding the needs and priorities of the organization • Identifying and engaging stakeholders • Assessing readiness for change PLANNING • Setting the scope of the project • Understanding the current state of a process • Defining goals and deliverables • Defining project activities and responsibilities • Estimating resources needed, along with financial and quality return on investment • Estimating duration and setting timeline for work • Developing management and communication plans • Acquiring needed approvals for project activities and budget EXECUTING • Coordinating people, activities, and resources • Generating and sustaining momentum through recognizing and celebrating milestones and small wins so the team builds on success • Communicating on progress, barriers, and successes • Team relationship development MONITORING AND CONTROLLING • Identifying key performance indicators • Addressing problems through intervention or process change • Developing systems to continue work or process following the project close • Reporting of project progress • Reviewing resource use, timeline, and goals COMPLETION AND CLOSING • Finalizing project activities • Transitioning monitoring to process owners • Disseminating changes • Identifying future projects/next steps

w w w.apic.org | 57


PROJECT MANAGEMENT SKILLS FOR IPS

the project leader must find meaning in the project, and connect to the reason it is being undertaken and how it fits into larger goals. Faked enthusiasm is easily identified and sends the message that the project is not important or meaningful. In the planning phase, it is also important to identify project milestones—intermediate goals—which can be used to monitor progress toward completion. Recognition and celebration of progress help sustain momentum and help the team build on prior successes. PROJECTS IN INFECTION PREVENTION

Because stakes are high with HAIs, there is often significant pressure to get quick results or make rapid changes in processes. The risk of moving too quickly is that without an understanding of current processes, and stakeholder engagement and participation in the change process, these changes are often not sustained and we wind up fixing the same problems over and over. The IP project leader must be able to articulate a clear vision of why the project is being

IndustryPerspectives_PS-Hpg_Dec'16_final.indd 58 | WINTER 2017 | Prevention 891483_Editorial.indd 1

1

undertaken, what the potential impact may be, and the potential risks that might be created by the work of the project, along with the risks of not successfully completing the project. This project management process is an excellent fit for pilot studies or focused implementation of new processes. Advanced preparation for long-term change management and dissemination of project work in the planning and execution phases can help in building support for project closure, or transitioning to other goals and activities Project management skills are a starting point in IP leadership development. The field is rapidly changing and becoming ever more complicated. In order to help organizations and care providers navigate the complex system, and the behavior changes that are often necessary to reduce and eliminate HAIs, IPs need to learn and understand tools from other fields that focus on project management, performance improvement, and change management. The development of additional tools specific to the needs of our profession and patients is also necessary.

By building our skills, we can work toward to creating a world without infection. Kelley Boston, MPH, CIC, CPHQ, FAPIC, is an infection preventionist and senior associate at Infection Prevention & Management Associates. References 1. Centers for Disease Control and Prevention. HAI data and statistics. www.cdc.gov/hai/surveillance/index.html. Accessed October 2017. 2.  Association for Professionals in Infection Control and Epidemiology. Vision and mission. www.apic.org/About-APIC/ Vision-and-Mission. Accessed October 2017. 3. Bubb TN, Billings C, Berriel-Cass D, et al. APIC professional and practice standards. Am J Infect Control. 2016;44(7):645-9. http://dx.doi.org/10.1016/j.ajic.2016.02.004. 4. Project Management Institute. A Guide to the Project Management Body of Knowledge (PMBOK® Guide), Fourth Edition. [United States]: Project Management Institute; 2009. 5. Six Sigma. DMAIC Roadmap. www.isixsigma.com/new-tosix-sigma/dmaic/six-sigma-dmaic-roadmap. Accessed October 2017. Additional Resources Association for Professionals in Infection Control and Epidemiology (APIC)—www.apic.org APIC Text Online—text.apic.org Chapters covering performance measures, quality concepts, infection prevention, and behavioral interventions. Project Management Institute—www.pmi.org Project Management RACI Matric—https://project-management.com/understanding-responsibility-assignmentmatrix-raci-matrix

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FEATURE

Making the

BUSINESS CASE Part 1: A financial primer for infection preventionists BY WILLIAM WARD, JR., MBA

INFECTION PREVENTIONISTS (IPS) are often asked to provide a business justification for their proposals. As clinical experts, however, they may lack the business knowledge to articulate the financial benefits needed to convince decision makers. This article is part one of a two-part series. Part one will enhance IPs’ knowledge of the business side of healthcare by describing the general business model that drives hospital financial performance, explaining how revenues and expenses behave as they combine to yield profits or losses, and demonstrate how improvements in infection control can result in positive “bottom line” results, thereby enhancing the probability of approval for various initiatives that reduce infections. Feel free to contact the author with questions or comments at wwardjr1@jhu.edu.

THE HOSPITAL BUSINESS MODEL

The first step in providing a business justification is to understand the hospital business model. How does the “bottom line”—the profit or loss of the organization—come about? What starts the ball rolling? How do revenue, cost, volume, staffing, equipment, and other elements combine to drive the financial condition of the organization? Perhaps the best way to answer these questions is to start at the end: the “bottom line.” The profit or loss of any organization is based on revenues and expenses. Simply stated, if the revenue exceeds the expenses, the result is a profit. If the expenses exceed the revenue, a loss results. But how does the revenue get to exceed cost? What causes revenues and expenses to rise or fall? Figure 1 visualizes the connections from profit or loss back to its genesis: volume. Volume can be described as patient days, admissions or cases, surgical cases, procedures, test, exams, or any other term for the activities causing work to be done (directly, for specific patients, a radiology procedure, for example; or indirectly, in a way that benefits groups of patients, maintenance on an MRI, for instance). Lacking some sort of volume, there is no activity.

Figure 1 – The hospital business model begins with patient care volume and circles back through the financial performance again to patient care volume in a continuous loop. Infection control initiatives impact all elements of the model.

Volume multiplied by price equals gross revenue—the amounts put on patient bills. If the price, sometimes referred to as the charge, for an outpatient visit is $450, then 100 such visits yield gross revenue of $45,000. Hospitals are never paid the billed amount. Medicare, Medicaid, United, Blue Cross, and the rest, take significant discounts, often paying less than 50% of the bill. These write-offs are referred to as

contractual adjustments. Self-paying patients are expected to pay the face value of the bill unless the provider offers them a discount, as is often the case for very large bills. When they do not pay, these write-offs are categorized either as bad debts (patients who could pay but choose not to) or charity care (those patients who just cannot afford to pay). The result of these write-offs is net revenue—the gross revenue net of the write-offs. w w w.apic.org | 61


The combination of revenues from inpatient stays (room and board, lab tests, diagnostic procedures, IV infusions, and so on), outpatient visits, and the like are all combined to yield total net revenue—gross revenue from all services, net of write-offs. It is important for business decisions to focus not on what is billed, but rather on what is collected—the net revenue. Volume also influences operating expense. While much of expense spending is fixed and does not change when volume rises or falls, some expenses, like medications, IV fluids, infusion sets, catheters, etc., do go up when volume rises and down when volume drops. Again, as with revenue, volume is the main driver of these expenses. Total expense is the combination of the fixed expenses (most labor, interest, depreciation, and some supplies) and the variable expenses. The revenues (money coming in) and expenses (money going out) are combined and result in profit or loss. Profits allow the organization to maintain infrastructure, invest in new services, grow existing service lines, purchase new technologies, and generally expand its capacity to provide services to patients. In turn, this expansion in capacity allows the organization to provide more services to patients, and in so doing, grow volume. If properly managed, the organization finds itself in a success loop. Again, as illustrated in Figure 1, volume leads to profits, which leads to increased capacity, which leads to increased volume. The cycle repeats, and the organization continues to grow and prosper. It should be pointed out that the key to success is growth—volume. Failing to grow is no different for an organization than for a human being. A diagnosis of failure to thrive (grow) for a newborn is quite troubling. Organizations that do not grow often go out of business entirely or are acquired by others. Successful hospital turnarounds in Maryland and Massachusetts, for example, found their genesis in increasing the volume of patient care services.1 Years ago, the Baltimore City Hospitals, now Johns Hopkins Bayview Medical Center, had amassed over $70 million of operating losses over a 10-year period. It was on the brink of closure because of its significant drain on the city’s coffers. The turnaround 62 | WINTER 2017 | Prevention

Figure 2 – Semi-variable costs are those that are generally fixed, but at certain levels of volume vary sharply before becoming fixed again. They are typically associated with dramatic changes in the scope of work as opposed to more routine modest volume growth.

to profitability was achieved not by reducing cost, but rather by increasing volume. Admissions and revenue grew by 20% per year, and the bottom line quickly turned from red ink to black ink. REVENUE AND EXPENSE BEHAVIOR

Hospital operating costs generally fall into three broad categories. Fixed, variable, and semi-variable. Semi-variable is sometimes referred to as “step cost” because of the way it looks when plotted on a graph. Fixed costs hold constant regardless of increases or decreases in volume. Costs can include such things as salaries, office supplies, utilities, interest paid on hospital debt, and the depreciation of a hospital’s fixed assets (scanners, hospital beds, etc.). With rare exceptions, these costs do not change when volume rises or falls. Variable costs rise and fall as volume rises and falls. These costs include such things as medications, IV supplies, patient drapes and gowns, exam gloves, and so on. Generally, more of these items are consumed as volume rises while fewer are consumed as volume declines. Semi-variable costs are fixed over a range of volume, then vary sharply before become fixed again. These costs are a bit of a wild

card and are associated with changes in scope of services. Consider the example of an outpatient clinic treating 100 patients a day. A staff complement of three people (a physician, a nurse, and a technician) handle this level of volume, treating 40, 80, or 100 patients a day. That staffing level represents fixed cost. But if the scope of business changes by the addition of a second group of 100 patients, another entire complement of staff will be needed. Thus, from the 101st patient up to and including the 200th patient, a second physician, nurse, and tech will be needed. The staff cost is fixed for the first 100 patients, then varies totally to handle the second group of 100 patients. In this way, fixed cost becomes variable with the addition of the 101st patient and then becomes fixed again until the 201st patient is added to the daily volume. In economic terms, this is an example of a diseconomy of scale—that 101st patient is extremely expensive and, frankly, financially disadvantageous because there will only be one added unit of revenue, but enough added cost to handle 100 patients. Figure 2 illustrates this concept and the reason they are often referred to as step costs. As shown, one cohort of staff (doctor, nurse, and tech) can treat up to 100 patients. From 101 to 200, another entire cohort is needed and, again, from 201 to 300, a third such cohort is required. In certain forms of


statistical analysis, one can assume a position at the midpoint of a normal distribution curve. So, too, in business it can generally be assumed that, lacking definitive information to the contrary, the organization is positioned at the midpoint of any of the horizontal volume plateaus (the large X in the figure). Based on this reasonable assumption, a modest increase in volume will not require an expansion of fixed costs. It will, however, add revenue and the hospital will profit from the increase in volume. For the most part, hospitals are managed and decisions are made based on costs being either fixed or variable. The semi-variable costs can’t be forgotten, but their presence is a relatively rare occurrence. Overwhelmingly, total hospital operating costs are fixed in nature (Table 1) with a smaller amount being comprised of variable costs. At the department level, the proportions can be quite different. Nursing units can be 90-95% fixed because of the intensity of their labor costs. The pharmacy may be split 50/50, with labor being 100% fixed and the medications 100% variable. The operating rooms, given the high cost of implanted devices and other surgical supplies, are largely variable. Some departments like finance and administration are 100% fixed. Are these proportions the same for every hospital? Certainly not. Does it matter if a hospital has slightly different proportions— say 85% fixed and 15% variable? Again, the answer is no. What is important is that hospitals are high fixed cost organizations. This reality provides financial leverage for improvement initiatives that increase volume and the associated revenue (100% variable with volume), while costs do not grow as rapidly (only 10+/-% variable with volume). A 10% increase in volume and revenue may be accompanied by only a 1% or 2% growth in cost, thus improving profitability.

In contrast to this, revenue is almost entirely variable with volume. The issue here is the reimbursement methodology. While some care is paid for on a fee-for-service (FFS) basis (the more services provided, the higher the bill and the payment), most care is covered by case-based reimbursement, led by Medicare and Medicaid. In excess of 60% of reimbursement is case-based nationally, while some organizations experience higher levels of case-based reimbursement. The remaining FFS business can include self-pay patients who are expected to pay 100% of their bill directly, and discounted FFS in which a third-party payor negotiates a discount off the hospital’s published charges. A small number of payments, primarily to small, safety net hospitals, are cost based. Consider, for example, a patient admitted to the hospital for coronary artery bypass graft surgery. A fee-for-service payor will get a bill of $70,000 or more depending on length of stay and the use of ancillary services. That payor will pay that bill based on pre-negotiated discount arrangements. If the patient is in hospital longer, the bill, and the discounted payment, will be higher. If the patient is discharged sooner or with less use of ancillary services, the bill, and its discounted payment, will be lower. Medicare, on the other hand, cares little about length of stay, ancillary usage, or the actual bill. It pays a flat amount based on the diagnostic coding regardless of the reality of services provided. DRIVING THE BOTTOM LINE VIA INFECTION CONTROL

Improvements in infection control almost always have a positive impact on a hospital’s financial condition. The literature demonstrates that infections have a significant and negative effect on length of stay. A methicillin-resistant Staphylococcus aureus infection

Table 1 Distribution of Overall Hospital Operating Costs by Type; Percentages by Category Cost Category

Total

Fixed

Variable

Salaries & Fringes

65%

60%

5%

Supplies & Services

15%

10%

5%

Interest

10%

10%

Depreciation

10%

10%

Total

100%

90%

10%

can add roughly 10 days to a patient’s time in hospital.2 Catheter-associated urinary tract infections, central line-associated blood stream infections, and Clostridium difficile infections similarly add many days to the length of stay. Events such as these block beds, reducing available capacity, and eliminating the hospital’s ability to admit other patients. Those missed admissions also mean missed revenue. A number of financial benefits result from reductions in hospital-associated infections and any improvement to clinical quality and patient safety. These include improvements to available operating capacity, cost efficiency, cost reduction, throughput and revenue generation, and balance sheet strength. Intangible improvements are also achieved. Available operating capacity: Patients occupying beds for longer than necessary because of infection block beds, thereby reducing the hospital’s capacity to admit new patients. Reducing infections shortens length of stay and increases available bed capacity. This increased capacity can be used to admit more patients, thereby increasing revenue. And since most cost is fixed, very little added cost is incurred by these new, incremental admissions. Cost efficiency: Since operating costs are largely fixed (perhaps as much as 90% fixed), total operating cost can be spread among more patients—the current ones and the incremental ones added because of unblocked beds. The result is lower cost per admission or cost per case. Simply stated, the same amount of cost divided by the increased number of cases yields reduced cost per case. Before reduction in infections: $15,000,000 of operating cost ÷ 1,000 cases = $15,000 per case After reduction in infections: $15,150,000 of operating cost ÷ 1,100 cases = $13,773 per case In this case, a 10% increase in cases (the denominator) accompanied by a 1% change in overall operating cost (the numerator) results in an 8.2% reduction in cost per case. This is the sort of operating efficiency finance leaders appreciate. Note that the operating costs grow only slightly owing to the low proportion of variable costs. Cost reduction: Sometimes, a reduction in infections does not result in increased admissions; no incremental cases are added. In this w w w.apic.org | 63


“BY UNDERSTANDING THE BUSINESS SIDE OF HOSPITALS AND THE ELEMENTS THAT DRIVE HOSPITAL FINANCIAL PERFORMANCE—THE REVENUES AND EXPENSES—PRACTITIONERS WILL BE BETTER ABLE TO DEVELOP A PROPER BUSINESS CASE AND DEMONSTRATE HOW IMPROVEMENTS IN INFECTION CONTROL CAN IMPROVE THE PROFITABILITY OF THEIR ORGANIZATIONS.” case, a lasting decrease in workload can result in a potential staff reduction. If the average census drops from 50 patients per day to 40 and remains at that level because of a reduction in infections, the nursing unit can be downsized. The reduction of 10 staffed beds out of 50 yields a potential staff reduction of 20%. One major caveat: If the unit is short staffed to begin with, the potential for achieving this staff reduction is limited and may, in fact, not be achievable at all. Some supply cost reduction is also possible as patients empty beds sooner. The variable costs associated with patient days can be reduced. But only the variable cost (perhaps as little as 10% of the average cost per patient day) will be reduced. Throughput and revenue generation: Because reducing infections shortens length of stay and increases bed capacity, throughput (the movement of patients into and through the hospital) improves. This can allow for a reduction in operating room case cancellations (along with the associated reimbursement penalties) and an increase in highly profitable surgical cases. Because more of the existing beds are available for use, emergency department divert hours can be reduced and the revenue that might normally bypass the hospital can be captured. Elective cases can be admitted sooner rather than being delayed. Balance sheet strength: Because the added revenue eventually converts to cash and is added to the balance sheet, funds are more readily available for equipment purchases and other investments, and the need for borrowing to increase capacity or to invest in new programs may be reduced. The millions of dollars invested in brick and mortar (i.e., facilities) and high-cost equipment is maximized. 64 | WINTER 2017 | Prevention

While many of the benefits of infection control initiatives are quite tangible, measured in hard dollars and cents, a few are harder to place a monetary value on. Nonetheless, there is value to be obtained from them, and even the intangible benefits can have an indirect financial reward. To use a culinary analogy, they are not the steak, but they are the béarnaise sauce that accompanies the steak. The intangible benefits include reduced malpractice claims owing to better patient outcomes; better reputation in the community, resulting in improvement in market share associated with improved clinical quality and patient safety; and higher satisfaction scores among patients, their families, and the hospital staff. CONCLUSION

IPs develop initiatives that reduce the incidence of infection, improve patient outcomes, and support the overarching notion of “first, do no harm.” They are often asked to describe the business case for approving their proposals and might be at a loss as to how. They may rely on literature, which promises massive reductions in cost, but in reality, does not meet expectations. By understanding the business side of hospitals and the elements that drive hospital financial performance—the revenues and expenses—practitioners will be better able to develop a proper business case and demonstrate how improvements in infection control can improve the profitability of their organizations. In so doing, they enhance the probability of approval for their proposals and, in turn, improve the care patients receive in their hospitals. William (Bill) Ward, Jr., MBA, is an associate professor of health finance and management at the Johns Hopkins Bloomberg School of Public Health, and an associate professor of nursing at the Johns Hopkins University School of Nursing. He is the former director of the Master of Health Administration Degree Program and the Sommer Scholars Public Health Leadership Program. Prior to joining academia, he was a senior healthcare operations and finance executive. References 1. Ward WJ, Jr., Health Care Budgeting and Financial Management, 2nd Ed. Santa Barbara, CA: Praeger, an imprint of ABC-CLIO, LLC; 2016. 2. Noskin GA, Rubin RJ, Schentag JJ, et al. The Burden of Staphylococcus aureus Infections on Hospitals in the United States. Arch of Internal Med 2005;165(15):1756-1761.


w w w.apic.org | 65


FEATURE

Talking to the

C-suite How to convert infection prevention words into C-suite language BY JODI LYNN VANDERPOOL, MBA, LNHA, CPPS, HACP

I

n healthcare, we are fortunate to have great diversity in those with whom we work. Roles, structures, experiences, expertise, style, communication flair, perspectives, and education encompassing all gradients of training of our teammates vary greatly. This variety, much like our strengths, can also be a weakness unless we know how to truly maximize our unique differences. The challenge of understanding each other is where we may have gaps to close. As a current C-suite leader, I have a great admiration and appreciation for professionals in infection preventionist (IP) roles who commit themselves to preventing infections; to preventing unfortunate complications; and to preventing unnecessary costs to both our patients and our health systems due to healthcare-associated infections (HAIs). With a pretense of positive intent, I have a personal bias that we all come to work to do the right thing and to work respectfully together. During this brief article, I will attempt to provide some insights on tactics to assist you with how to convey, “This IS Important” to your C-suite leaders. Some of you may have verbalized to, or about, your leader (or at least mumbled under your breath), “You just don’t understand.” As a current C-suite linguist, I am wise enough to humbly acknowledge that I 66 | WINTER 2017 | Prevention

do not know it all and just when I think I do...I don’t. Therefore, without the translation of infection prevention to C-suite language, I am confident the full value of infection prevention strategies, data, action plans, and outcomes, cannot and will not, be realized. And what a loss that would be! Measures of healthcare quality are displayed in many different formats, each utilizing different definitions. Even the most skilled healthcare worker, who is a subject matter expert, must be conscientious when reviewing the information to ensure understanding and true clarity. We also know that there are more hospitals contributing data for public benchmarks, and definitions continue to be updated as well. Now add to the equation a leader who is committed to meaningful transparency and a review of required data elements and capabilities.

©ISTOCKPHOTO.COM/sturti

Without appropriate caution, that could be a dangerous combination. It carries potential for unintentional misinterpretation or misleading conclusions. Don Berwick, MD, former administrator of the Centers for Medicare & Medicaid Services, infamously stated, “[T]o fix medicine we need to do two things: measure ourselves and be more open about what we are doing.” It sounds fairly easy to commit to being more open about what we are doing. However, when attempting to apply it to practice, the challenge becomes real. The actions below will help IPs apply the second portion of Don Berwick’s statement, and be more open with the C-suite and leadership about what they are doing. • Keep the patient at the center.


• Discuss with clarity the definitions for any data or metric you capture, measure, review, and utilize. • Describe the impact of the data to current and anticipated components of hospital incentive and penalty programs (operators on all levels can connect with this key factor). • Discuss the significance of HAIs in the hospital reimbursement program, (if this... then that...). • Provide concise information and a proposed strategy, incorporating a business strategy as able, to reduce HAIs. Successful leaders and responsible board members not only want to understand, but they are expected to understand the details regarding the impact of the quality and

infection prevention and control programs in their health systems. I have found that utilizing a standard and consistent executive summary approach is the most effective way to provide enough information with the right amount of applicable details. The use of a standardized summary can help ensure the most common and most pertinent questions are answered prior to being asked. The value in using a consistent format is that the recipient, being an individual, group, or committee, who receives the information, is already familiar with the format and comfortable with the compilation of what is included and/or not included. The focus of infection prevention reports can then be aligned with the intent of the “ask” or

“COMING TOGETHER IS PROGRESS; WORKING TOGETHER IS TEAMWORK; AND STAYING TOGETHER IS SUCCESS.” the purpose for providing information to the recipient. There are two different formats of executive summaries you may want to review and consider utilizing for your health system. The different formats can be beneficial in w w w.apic.org | 67


EXECUTIVE SUMMARY TEMPLATE:

Example #1

The first executive summary template is one that provides greater detail and allows the recipient to become involved and knowledgeable. It provides information in a concise format that ensures key details are not overlooked by complexities that do not add value.

Request

What are you asking recipient to do? (e.g., informational, action-required, feedback, etc.)

Problem Statement

Why this is coming before this leader/committee and what part of the role or charter is this fulfilling? (e.g., high-level overview of the issue)

Requesting Entity

Who is making the request? e.g., individual, department, entity

Issue Background

Brief background providing contextual information to aid in execution of the request, including previous levels of approval when appropriate

Value-Add

How does this request add value to the organization? How does the request align with the strategic vision and mission of the organization or Triple Aim? (i.e., better care, lower cost, better health)

Financial Impacts

What are the fiscal implications of the request?

Interested Parties/Key Stakeholders

List all parties involved in the issue at hand to allow for the identification of potential gaps or conflicts of interest

Accountability/Metrics of Success

How will the request be measured? How is success defined?

Management’s Recommendation

Given the background, what are your recommendations or actions proposed for this? (e.g., implement more broadly or take to other stakeholders, approve, endorse, feedback?)

Attached Documents (in order of presentation):

This allows the recipient to have access to the document, even though the executive summary should eliminate the need to review

68 | WINTER 2017 | Prevention

EXECUTIVE SUMMARY TEMPLATE:

Example #2

This second format of an executive summary works well when used for quality committees, leadership groups, and boards. It does not provide as much detail, but information is able to be presented orally to ensure proper context. The presenter has the ability to answer baseline questions that may not be clear to the diverse group of recipients.

Request

What are you asking the committee or board to do [note if the topic is informational or if action is required] and who is making the request? (list the individual, department, entity, or board/committee)

Issue Overview

Why is this coming before the board? Address all of the following elements: Problem Statement – High-level overview of the issue, including how this request adds value to the organization and aligns with the mission and vision. Issue Background – Brief background providing contextual information to aid in execution of the request, including: previous levels of approval when appropriate, and the fiscal implications of the action (specifically address if the request requires capital funding, if it is included in the five-year capital plan, and if a philanthropic offset is available and expected). Talking Points – List the three key take-aways for the leadership committee or board.

diverse environments where information is shared, whether a summary is provided in packets for review in meetings; presented to an executive individually; or disseminated electronically to a defined group of stakeholders. Whichever distribution route you choose to utilize, it may be beneficial to share the intended formats with stakeholders and obtain feedback on the communication process prior to implementation. This will give you the opportunity to ensure that key stakeholders recognize the value of the report, and support your process to ensure transparency and success from the beginning. Regardless of the format selected, it will be wise to follow the advice of Occam’s razor: “If there are two ways to explain something, the simpler way is probably the best”; and Einstein: “Make things as simple as possible, but not simpler.” With a high level of commitment, we can all become skilled multi-linguists who speak both infection prevention and C-suite. We can make a greater impact together than we could ever do alone. Jodi Lynn Vanderpool, MBA, LNHA, CPPS, HACP, is the system vice president of quality operations for St. Luke’s Health System in Boise, Idaho. Her commitment to the profession and her team is ensuring that those who provide the support and quality leadership receive the optimal support to be able to make significant contributions to the lives of those they serve and serve with. She was the 2017 recipient of the Healthcare Administrator Award.

READ MORE ABOUT TALKING TO THE C-SUITE IN THE AMERICAN JOURNAL OF INFECTION CONTROL A model for choosing an automated ultraviolet-C disinfection system and building a case for the C-suite: Two case reports. Spencer M, Vignari M, Bryce E, et al., American Journal of Infection Control, Vol. 45, Issue 3, p288–292. Business continuity and pandemic preparedness: US health care versus non-health care agencies. Rebmann T, Wang J, Swick Z, et al., American Journal of Infection Control, Vol. 41, Issue 4, e27–e33. Writing a Successful Business Case for Methicillin Resistant Staphylococcus aureus (MRSA) De-isolation: ‘Get Out of Jail Free Card’. Dickson A, American Journal of Infection Control, Vol. 43, Issue 6, S38–S39.


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INDEX TO ADVERTISERS BEDPAN WASHER MEIKO�������������������������������������������������������������������31 www.meiko.us

HAND HYGIENE BD (CareFusion)����������������������������������������������������60* www.bd.com/ChloraPrepSkin

INFECTION RESISTANT COATING The Sherwin-Williams Company����������������������������7 www.swpaintshield.com

CLEANING, DISINFECTION & STERILIZATION Molnlycke Health Care������������������������������������������11 www.Hibiclens.com/HUBS PDI, Professional Disposables International�������� 40* www.pdihc.com Sealed Air Diversey Care����������������������������������������9 www.sdfhc.com Steriliz, LLC�������������������������������������������������������������3 www.steriliz.us Tru-D Smart UVC��������������������������������������������������24 www.tru-d.com Virox Technologies Inc.�����������������������������������������36 www.virox.com/PeroxiGirl

INFECTION CONTROL PRODUCTS Healthmark Industries Co.������������������������������������69 www.hmark.com Medline Healthcare�����������������������������������������������18 * www.medline.com Nanosonics Inc�����������������������������������������������������17 * www.nanosonics.us SEAL Shield���������������������������������Inside Front Cover www.sealshield.com

IV CARE SOLUTIONS 3M Vascular Care Pathways���������������������������������23 www.3M.com/IVCarePS

CLOSED SYSTEM NEEDLE SAFETY DEVICES B. Braun Interventional Systems Inc. ����������������������������� Inside Back Cover* www.bisusa.org DECONTAMINATION & STERILIZATION EQUIPMENT Clordisys Solutions, Inc.����������������������������������������20 www.clordisys.com

APIC_IIPW'17_ThnxChamps_PS_Hpg_1.indd 70 | WINTER 2017 | Prevention 891482_Editorial.indd 1

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INFECTION PREVENTION PRODUCTS & SERVICES Eloquest Healthcare����������������������������������������������21 www.reliatectpostop.com INFECTION PREVENTION SOLUTION - CONSULTING Xenex Disinfection Services��������������������������������39* www.xenex.com

MEDICAL DEVICES & INSTRUMENTS 3M ��������������������������������������������Outside Back Cover www.go.3M.com/trustedscience Retractable Technologies, Inc.������������������������������35 www.retractable.com NASAL ANTISEPTIC Global Life Technologies Corp.�����������������������������27 www.nozin.com WATER TESTING SOLUTIONS IDEXX �������������������������������������������������������������������49 www.idexx.com

*denotes an APIC strategic partner..........www.apic.org/partners

10/25/2017 1:35:29 PM 28/10/17 2:45 am


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Profile for APIC Publications

Prevention Strategist—Winter 2017  

Prevention Strategist—Winter 2017