Create a Culture of Healthcare Site Compliance in 5 Simple Steps

The recent Center for Disease Control (CDC) report on Antibiotic Resistance Threats in the United States (2019 AR Threats Report) includes the latest national death and infection estimates that underscore the growing risk of antibiotic resistance in the US.

According to the report, more than 2.8 million antibiotic-resistant infections (superbugs) occur in the United States each year, and more than 35,000 people die as a result. In addition, more than 200,000 cases of Clostridioides difficile (C-diff) were tracked in 2017 with over 12,000 deaths. Director Tom Frieden, M.D., M.P.H. has stated that the CDC soon plans to support Antibiotic Resistance Prevention Programs in all 50 states.

Clinical practitioners are tasked with hyper-vigilance in combating the spread of bacteria in both the health care setting and patient communities.

Mistakes in infection prevention can impact both quality of life and may cause untimely death. These errors can also put medical providers at risk of legal action. Healthcare-associated infections are a serious and shockingly commonplace matter, causing billions in direct medical costs annually following severe MRSA or C. difficile infection incidents.

Legal ramifications are not the only issue. If a complaint is filed on behalf of an affected patient with the CDC, Joint Commission or a states’ health services department; that institution or individual could lose accreditation or licensure with the state, or in a worst-case scenario, CMS could ban access to the Medicare program, which could be financially devastating.

Of course, one of the most effective methods of addressing this ever-present threat is by ensuring consistent infection prevention and control practices by employing site-wide awareness. According to the World Health Organization, 1 in 10 patients get an infection while receiving care, and an effective infection prevention and control program can reduce health care-associated infections by at least 30%.

While infection prevention is a standard practice in the U.S., many clinical staff members report that they are not 100% clear on the requirements. Creating a culture of compliance and adherence to safe practices of infection control is widely considered to be one of the very best ways to combat errors in this area. A strategic approach to creating a successful program begins with a simple 5-Point Plan.

1. CHOOSE A LEADER: Begin by assigning someone in the organization to the role of “infection prevention compliance officer”. Choose someone who has the respect of staff and solid organizational skills. It will also help if that individual is already versed in IP standards, but if not, now is the time to assign them to complete and proper training. Training should include a focus at the management level covering infection prevention principles and practices as well as documentation requirements, program building, staff engagement and reporting requirements. If the site has special infection prevention elements such as specific device maintenance, connect with the device manufacturer for detailed disinfection and cleaning instructions.

2. CREATE OR ENHANCE POLICIES AND PROCEDURES: After the assigned officer has completed or refreshed appropriate training, they should begin their process by examining current infection prevention policies and decide if they reflect best practices. If there are no firm policies and procedures in place, they should create them and review them with management to ensure complete. The CDC offers infection control guidelines to help frame these materials, however they should reflect the specific healthcare environment in which they will be maintained. These policies should also be reviewed annually to include any new equipment or process steps. All staff members should be required to refresh their familiarity with this document annually as well.

3. ESTABLISH AND MAINTAIN A TRAINING AND AWARENESS PROGRAM: The officer should also review processes for educating personnel about standards and make certain they can provide proof of training and validation in the form of a dated certificate preferably delivered by an accredited educational provider. If an efficient training method or model has not yet been implemented, this should be done immediately. Awareness level training should include at a minimum:

  • Infection Control and Barrier Protection
  • Personal Protective Equipment (PPE)
  • Cleaning Disinfection and Sterilization (CDS)
  • Needle-Stick and Sharps Safety (NSS)
  • Bloodborne Pathogens Prevention (BBP)
  • OSHA for Healthcare Environments (OSHA)
  • Sepsis Prevention
  • TB Prevention
  • HIV/AIDS Prevention
  • Hand Hygiene
  • Environmental infection control and isolation precautions
  • Specific device cleaning and disinfection procedures for the environment

Training should be provided both when onboarding a new employee and annually as part of a staff training requirement program. Reminders in the form of regular messaging to staff, signs and regular site meetings wherein the IP compliance officer engages in discussions with staff members to review any incidents or new processes.

4. PROVIDE PATIENT AND CAREGIVER SUPPORT: Following any procedure which requires the patient (or caregiver) to provide personal after-care that would involve infection prevention precautions, include instructions and require staff to explain those instructions before discharging the patient. Include or recommend consumables that will help the patient protect themselves from infection when following the IP steps. Follow-up with patients to confirm compliance and record those calls, messages or conversations in the patient record for legal and ethical protection.

5. DOCUMENT ALL ACTIONS AND ACTIVITIES RELATING TO INFECTION PREVENTION: The IP Officer should create step sheets and accompanying checklists for each role in the environment as it relates to the infection prevention procedures. All staff who address the components of the infection prevention program should document their steps daily and the IP Officer should review those documents regularly to ensure that they are complete, timely and accurate. The CDC offers resources including infection prevention assessment tools which may be employed by the IP Officer in developing this aspect of the overall program.

By following this simple 5-point plan, healthcare sites will be able to streamline their infection prevention strategy and create a working culture of infection prevention compliance to aid in the avoidance of errors and any incidents of HAI.

TRAINING RECOMMENDATION: 4MedPlus offers accredited online compliance training bundles for infection prevention that cover many of the required annual subjects with verified certificates of successful completion and include national CE credit for RNs, LPNs, Physicians and PAs. These bundles work well for onboarding new staff and for building annual training programs. IP Officer Training is also available for the management role level.

Author: Wendy Whitmore, CLO