Beyond the Basics: Taking it to the Next Level Infection Prevention and Control Committee

1. Connie Steed, MSN, RN, CIC Director, Infection Prevention Beyond the Basics: Taking it to the Next LevelInfection Prevention and Control Committee

2. Objective 1.Discuss whether an Infection Prevention and Control (IPC) committee is required by guideline and regulating agencies. 2. List characteristics of a successful IPC meeting. 3. Identify at least 2 strategies to facilitate engagement and attendance by IPC committee members. 4. Discuss what kind of data and information should be presented at IPC committee meetings.

3. IPC Committee Do you have to have one?

4. CMS Infection Control Conditions of Participation Interpretive Guidelines §482.42(a)(1) • The infection control officer or officers must develop, implement and evaluate measures governing the identification, investigation, reporting, prevention and control of infections and communicable diseases within the hospital, including both healthcare–associated infections and community-acquired infections. Infection control policies should be specific to each department, service, and location, including off-site locations, and be evaluated and revised when indicated. The successful development, implementation and evaluation of a hospital-wide infection prevention and control program requires frequent collaboration with persons administratively and clinically responsible for inpatient and outpatient departments and services, as well as, non-patient-care support staff, such as maintenance and housekeeping staff.

5. The Joint Commission • Standard IC.01.01.01 Identifies the individual(s) responsible for the infection prevention and control ( IPC) program • Standard IC.01.02.01 Leaders allocate needed resources for IPC program. • Standard IC.01.03.01 Identifies risk for acquiring and transmitting infections. …input from at minimum IP personnel, medical staff, nursing and leadership

6. The Joint Commission ( continued) • Standard IC.01.03.01 Identified risks for transmitting infections. • Standard IC.01.04.01 Based on identified risks, the hospital sets goals to minimize the possibility of transmitting infections. • Standard IC.01.05.01 Has and infection prevention and control plan …Hospital components and functions integrated into the IPC activities. …Methods for communicating responsibilities and reporting data.

7. The Joint Commission ( continued) • Standard IC.01.06.01 Prepares to respond to influx of potentially infectious patients • Standard IC.02.01.01 Implements IPC plan • Standard IC.02.02.01 Reduces the risk of infections associated with medical equipment, devices and supplies.

8. The Joint Commission ( continued) • IC Standard.02.03.01 Works to prevent the transmission of infectious disease among patients, licensed independent practitioners (LIPs), and staff. • IC Standard.02.04.01 Offers vaccination against influenza to LIPs and staff. • IC Standard.03.01.01 Evaluates the effectiveness of IPC plan …Are findings communicated at least annually to the individuals or interdisciplinary group that manages the patient safety program?

9. IPC Program Cycle: Committee should facilitate program

10. Organization-wide: Integrating IPC • Integrating: To make into a whole by bringing all parts together; unify. IPC Committee can serve as key unifying forum

11. Do You Need IPC Committee? • Not necessarily!!! But… There needs to be a means to, in a collaborative fashion, report, analyze, and make decisions specific to the IPC program. • Various committees are used: e.g. Quality Management, Medical Care, Safety committees • Need to be able to prove interdisciplinary work/ communication and integration… • Minutes—document your activity.

12. Each Hospital is Unique • Culture • Organizational structure • Size and complexity Reporting/ communicating forum needs to be what works best for the organization.

13. GHS example Quality Management Committee Medical staff Process Improvement Committee GHS IPC Committee Hospital epidemiologist, IPs, Pharmacy, MDs, Nursing, Sterile Processing, OR, Employee Health, Lab, VP Quality; Public Health rep, RT , Ambulatory Care, Home Health Meet every other Month Key focus: IPC program oversight, data analysis, decision making, recommendations to leadership • Sterilization • Subcommittee • Key focus: Instrument/ equipment • Antibiotic Stewardship • Subcommittee IPC Policy and Procedure Subcommittee Key focus: Standards of Practice

14. Hospitals • GMMC: Academic Medical Center: IP Team meets every other week: Medical Director, IPs, others as needed • PMH: Short stay surgical hospital: Quality Committee meets monthly, diverse membership • HMH: Small Community Hospital: IPC Committee, meets quarterly, membership similar to GHS IPC Committee , Also reports to Quality Committee • GrMH: Small Community Hospital: Medical Care Committee, diverse leadership • NG LTACH: Long Term Acute Care: (QCPC) Quality Committee, meets monthly; diverse staff and leaders; Also reports to Steering Group All facility IP representatives report to: Safety Committees and Medical Care Committees (ICRAs)

15. Effective Committee Characteristics • Clear Purpose/ vision • Good leader/ facilitator • Organization: Agenda, timekeeper, minutes • Membership: Engaged; appropriate to purpose of committee; diverse; prepared • Method of communicating and reporting is consistent/ easy to understand • Appropriate content to purpose • Can make decisions/ recommendations

16. IPC Committee Purpose Authority / power of committee needs to be clear • Advisory • Review ideas from infection control team • Review/ Analyze surveillance data • Expert resource • Help understand hospital systems and policies • Decision making • Assesses Plan and conducts or reviews infection control risk assessment • Review and approve policies and surveillance plans • Policies binding throughout hospital • Education • Help disseminate information and influence others Edward O’Rourke, M.D , Harvard University –Harvard Medical School

17. IPC Committee Leader/ Facilitator • Who is your Chairman? MD? You? • Are they/ you effective? Engaged?; interested?; attends?; effective communicator? • Leader: opens the meeting and takes group through agenda and encourages decision making • Facilitator: Helps prepare for meeting to ensure it goes smoothly Keys to success: If leader and facilitator aren’t the same person, communicate prior to meeting regarding agenda; Make sure you have the right person chairing committee.

18. Creating a Shared Need • Are all members of the committee aligned in terms of the need of IP program and for change? ( ICRA>> Plan development) • Have we framed the need for committee/ IP program such a way to reflect the concerns of the customers and key stakeholders? • Would each team member deliver essentially the same message regarding the need for IP program and committee if asked by someone outside the team? Creating a shared need involves framing the need to appeal to the interest of key stakeholders/ Committee members.

19. IPC Committee Membership: Multidisciplinary: Key Influencers, interested • MDs • Nursing • Leadership • Employee Health • Infection Prevention • Sterile processing • Lab • Pharmacy • Public Health • Others/ ex-officio: e.g. Environmental Services

20. Rating Sources of Causes/Reasons for Resistance (0-100%) Resistance Lack of understanding Political Cultural Mobilizing Commitment- Sources of Resistance To understand the nature of resistance. Identify by Group* *Use groups from the key constituents Map

21. IPC Committee Membership How do you get them to attend? They have to want to attend. • Ask members for input to improve/ facilitate good meetings- make this part of annual assessment • Qualifications to be on the committee Interest Represent group in hospital Experts in their field Diplomatic What do you do if key influencer is disruptive? Good communicators Care about the membership, change it up if needed to improve involvement

22. Role definition: Building the Team/ Committee A.R.M.I. analysis IPC Plan KEY STAKEHOLDERS STARTUP IMPLEMENTATION EVALUATION A – Approval of issues such as project scope, resources, and ultimately team recommendations for improvement R - Resource to the team, whose expertise, skills, or influence may be needed on an ad hoc basis. M - Member of team, with critical working knowledge of the problem and/or process . I - Interested party, who will need to be kept informed on direction, findings, if later support is to be forthcoming.

23. What are We To Do With This Information? • Understand that we are change agents and the committee held decide/ direct the program. • Understand the importance of preparation when facilitating, leading a team or committee. Go slow to go fast. • Use tools when motivating a commitment to the IPC program and/ or effecting major change: • Creating a shared need/ Vision • Stakeholders • Mobilizing Commitment

24. Understand the Cultural condition of your Organization Example GHS in Cultural Transformation • CEO-Mike: Leading us to go from being a victim to making a difference through ourselves. • VP Quality-Tom: Leading us to think through things to assess the barriers to change and make a plan to influence them. Where does the IP program fit? Is it seen as positive or negative? A change force…..

25. Meeting Schedule of Topics Meeting Frequency and timing can influence attendance

26. Committee Organization / Content Agenda *Other Infection Preventionists conducting surveillance

27. Method of Presenting Information Material ( needs to hold attention) • Paper/ handout • PowerPoint • Verbal discussion Room Set up • Classroom • Meeting set up Planning is key

28. GHS Overall Weighted Hand HygieneCompliance Rates • Report generated November 21, 2011

29. Hand Hygiene Compliance Rates Note: Baseline Jun-Sep ‘09. • Report generated November 21, 2011

30. 08-09 Season Peak: 131

32. GHS-SIP Data Urinary Catheter RemovalJuly 1, 2009-May 31, 2011

34. March- April 2011- VRE cluster in 4003 and 4005. Education and enhanced rotational cleaning, 3M Cleantrace testing and culturing done MSICU VRE Isolates from patients and surfaces sent to Johns Hopkins for PFGE. Possible HCW transmission via the environment and hands. .

35. PMH MDRO RateJill Lindmair, BSN, RN

36. GHS Adult CLABSI Quarterly Rates Over Time [CY’08 Q2 – CY’10 Q4] • Report generated Oct. 17, 2011

38. GrMH, HMH, PMH CLABSI Data

39. CLABSI Prevention and Cost-Savings (GHS Adult) • Report generated Oct. 17, 2011

40. GHS Surgical Site Infections • Report generated Sep 20, 2011

41. GHS Surgical Site Infections * New risk adjustment methodology • Report generated Sep 20, 2011

42. Summary • The organization needs to have a means to integrate IPC program: • Data analysis • Recommendations/ follow-up • Policy development/ approval • Means to bring people together to address ICRA and program planning • Communication: multiple committees/ team • IPC committee is worth the time if it serves a purpose in the organization’s culture/ structure. • Committees/ teams need to be organized/ planned; members need to be engaged to make a difference

43. Thank you!!!! • csteed@ghs.org