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Validate Infection Prevention &
Responsibilities
Leaderships role in lowering infection rates
Validate Infection Prevention &
Responsibilities
How do you engage executive leadership and
physician leadership in infection control efforts?
Need to know the numbers !
 1.7 million infections annually
 99,000 deaths each year
 Cost of $20 Billion annually
 What is your infection rate? Review for the past 2-3 years?
 Know your data, pull up the HospitalCompare , U Compare
HealthCare, Health Grades etc
 Health Grades has three scores: Worse than average, Average,
and Better than average.
 Satisfaction survey are viewed by the public, payers, industry
and Administrators
Who is looking?
 Institute Healthcare Improvement
 Center for Medicare and Medicaid Services
 National Quality Forum
 Center for Disease Control and Prevention
 IHI 5 Million Lives Campaign
 Consumer Advocacy Groups
 Accrediting agencies: TJC, DNV, CMS
 Third Party Payers
 Leapfrog
 Agency for Healthcare Research and Quality
 And you should be looking at your hospitals score
Fact or Fiction?
 So what do all these entities see?
 How do they interpret the data ?
 This data is used in contract negotiation for industry in
purchasing healthcare for their employees
 On HealthGrades report under the 13 points for Patient
Safety, Campbell County Hospital scored 12 average and
Billings Clinic had 7 average , Wyoming Medical Center has 3
in the average score , Mayo has 2 average score, Cleveland has
2 average scores.
 This is public information ! Look up your facility!
Who Are The Big Players?
 These are the players who have done research, published
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studies on quality care and outcomes:
Kaiser-Permanente
Pennsylvania P4P
Michigan study by Sanjay Saint, MD, MPH
The SHEA-IDSA Compendium: A Framework for
Prioritizing
CDC/NHSN
National Quality Forum’s “Safe Practices for Healthcare”
Looking for Leadership ……
 So with all this information you are getting ready to meet
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with your leadership team (recommend not leaving your
immediate supervisor out) regarding:
Funding
Visible support from administration
Visible support from clinical leaders
Sharing data
Adequate staffing (or workload reassignment if needed)
So now comes the selling part…..
 HAI’s are a national priority and top concerns for patients….
 Chief executives and leadership have an essential role to lead
the institution….
 Every CEO must address this….consider the effect on
hospital brand image when infection rates are published by
media as mediocre or as worse than national average!!!!
 Hospital executive must be active and visible in promoting
established HAI strategies by making rounds…engaging staff
 They need to walk the talk. Making rounds and talking about
hand hygiene to staff, the word will go around!
CEO & Leadership
 Don’t assume they know all about preventing HAI’s
 Our language may put them at odds..
 Show data….
 Show what are the best practices that have the studies to
validate the data…
 Do your research before you see the CEO and Leadership to
sell your program… prepare yourself for questions…
 Don’t get flustered and don’t become defensive…
 Know who are your champions, strategize and clearly know
what you are requesting …
What do the Successful Hospital’ Do…
 Cultivate a culture of clinical excellence and effectively
communicated it to staff
 Focused on overcoming barriers and dealt directly with
resistant staff or process issues that impeded prevention of
HAI
 Inspired their employees
 Think strategically while acting locally by:
 Politicking before crucial committee votes
 Leveraging personal prestige to move initiatives forward
 Forming partnerships across disciplines
But….Understanding Yourself!
 Where are you in the IP competency Model?
 Do you have a professional development plan?
 Have you shared it with your hospital leadership?
 Are you a member of the professional organization?
 Are you certified? Is certification in your future?
 Where are you on the APIC Competency Model?
 Infection Prevention& Control Domain
 Technical Domain
 Performance Improvement & Implementation Science Domain
 Leadership & Program Management Domain
Where are you on the Career Stage
Model?
 Novice:
 First 24 months, confident about clinical skills, device
management, and key prevention strategies
 Middle:
 Between 2-5 years in infection prevention , obtained CIC
certification, understand your budget, fully knowledgeable of
the software being utilized
 Advanced:
 5 + years, continues holding certification, present at local or
regional events, recognized leader in infection prevention, be at
the leadership table!
OK…You are ready to meet with …
 Know your reporting line, CEO? VP Patient Services?
Quality?
 If you have several layers to go through, best have your
presentation ready to present to your immediate supervisor
 Present your program: data from your facility, health grades
report, infection prevention plan, Dashboard Data, infection
control plan and others depending on your facility
 Transitioning from benchmarking to zero tolerance and
clinical accountability, but you cannot do this alone!
OK…You are ready to meet with …
 Remember you have a lot of Power Players supporting you!
 What do all these entities have in common?
 Best practice IS evidence-based:
 Variation is the enemy of Quality and Safety
 The goal is not to standardize practice….. It is to practice to
the highest standards
 Your goals is to then present this to leadership !
CMS announcement in 2007
 As of October 2008 payment will not longer be made for the
following Hospital-Acquired Conditions:
 Catheter-Associated Urinary Tract Infections
 Vascular-Catheter Associated Infections
 Surgical Site Infections – Mediastinitis after Coronary Artery
Bypass Graft (CABG)
 VAP and Staph aureus septicemia in 2009
 Remember CMS is 2 years behind payments to hospitals.
 And don’t think other third party payers won’t join CMS
Precursor to This Announcement
 SCIP Criteria
 Ventilator Bundle
 Central Line Bundle
 Influenza & Pneumococcal Vaccine requirements
 HICPAC Guidelines on Preventing Infection
 NQF Safe Practices in 2003
 OH!! WellPoint won’t pay for preventable adverse events!!!!
 A licensee of the Blue Cross and Blue Shield Association, the
company insures 35 million people in
CA,CO,CT,GA,IN,KT,ME,MS,NE,NH,NY,OH,VI,and WI
Forces of Change…..Use Them!
 “One of the greatest challenges is to attain, maintain and
advance professional competence in an evolving health
care environment” *
 Expectations of Payers, Employers, Peers and Patients
 Forces of Change: The Public
 They chose their provider
 They chose their healthcare facility
 They read HealthGrades
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* AACN
Presentation
 Concise
 Don’t overwhelm the with too long of a presentation
 Data… speaks for itself… almost:
 Your Infection Prevention and Control Plan
 Your Dashboard, what are you monitoring
 Your educational goals for the clinical departments, ancillary
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departments and others ( remember your Board of Trustees)
Your scope of Service
Annual Risk Assessment Plan
If Employee Health is part of your scope, add your Employee Health
Plan
Plan your certification in Infection Prevention
Presentation
 SHEA-IDSA Compendium: Prioritizing prevention strategies
A framework for prioritization:
 Central line bloodstream infections
 Ventilator-associated pneumonia
 Catheter-associated urinary tract infection
 Surgical site infection
 Organism-specific HAI categories of MRSA and Clostridium difficile
Critical Review of Your Plan
 When you review of all that is required for the improvement
of patient safety and quality:
 Built in strategic thinking,
 Eliminate barriers to compliance
Reliability Concepts for Prevention Plan
 Hand Hygiene
 Built in processes that are not solely reliant on memory
 Review underlying processes when reviewing failures
 What level of performance is reliable?
 Must staff rely on memory to recall critical steps?
 Distractions interfere and likely lead to failure of compliance
 New and untrained staff?
 Multiple steps to complete the process?
 Is one training or educational session adequate?
Executive Leadership and Success
 Assess your hospitals performance , complete a gap analysis
 Use the gap analysis as a tool and standing agenda item at
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your committee meeting
Invest in software or technology support to assist your
infection prevention team
Require every HAI initiative to have an executive leadership
sponsor
Round in all department regularly and talk to staff
Spend time networking with infection prevention
practitioners
Leadership
 If you have the best leadership support….. Nominate your
executive for APIC’s Healthcare Administrator Award , if
not….
 Chief executives and hospital leadership teams have an
essential role in driving reduction and prevention if HAI’s
 It is important to prioritize efforts and base strategies on
scientific evidence and recommended best practices
 The National Quality Forum notes Safe Practices1 as
“Leadership Structures and Systems,” citing that leadership
systems must be designed to identify gaps in patient safety
with accountability for gaps residing with hospital leaders.”
So Now Go For It!!!!
 Don’t be discouraged
 Be able to compromise
 Before you go into your meeting with Leadership, know
what you can negotiate on, what could be on the plate for
next year, and what absolutely will give you most for your
money!!!!
 Questions?????
Questions:
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 Baerbel Merrill MS,BSN, CIC
307 689 3942