Download IPP Plan - Oregon Patient Safety Commission

INFECTION PREVENTION
PROGRAM PLAN
INSTRUCTIONS:
The infection prevention program (IPP) plan should include descriptions of:

Use of evidence based guidelines, including documentation of those specific guidelines

Surveillance activities (including surveillance and quality improvement indicators) and how
the findings will be evaluated

Process for investigating outbreaks of infectious diseases

How all infection prevention components, functions, and activities are integrated

Method used to communicate concerns, and program findings to LIPs, staff, visitors, patients,
families.

Method to report infection control related concerns externally to other organizations
The IPP plan should address the following CMS questions:

Does the ASC have a system to actively identify infections that may be related to procedures
performed?

How does the ASC obtain this information?

How is supportive documentation confirming the tracking activity maintained?
The Infection Control Committee (ICC):

The ICC should review all risk assessment documents and approve of the findings

The ICC needs to be involved with the annual program evaluation

The ICC needs to approve of IPP annual goals and plan
Results of annual evaluation and planning should be shared with all staff. At least annually and
when risks significantly change:

Evaluate the plans successes, shortcomings, and barriers

Prioritize risks, plan goals and activities to mitigate the risks

Use findings to revise the plan
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PROGRAM & RISK BACKGROUND
The [insert your facility name] ASC performs over [insert #] surgical procedures each year. The
Infection Prevention Program (IPP) at the ambulatory surgery center provides service to a patient
population that includes the following patient populations:
[Insert your scope of services. Example:
 surgical specialties, including orthopedic, plastics, and gynecology
 adult oncology patients
 general medicine patients
 women’s health
 pediatric patients between 4-18 years of age]
The IPP is staffed by one 0.20 FTE Infection Preventionist. [Note: Include the FTE percentage
worked by the designated licensed Infection Control professional]. The Infection Preventionist is an
Oregon licensed RN, who is certified in Infection Control (CIC) and a member of the Association of
Professionals in Infection Control (APIC) national and local chapters. The designated Infection
Preventionist will:

Provide staff with consultation on infection prevention and control issues

Act as the infection prevention liaison to, and resource for, the community and state health
departments
MISSION & OBJECTIVE
The main objective and mission of the Infection Prevention Program (IPP) is to provide and
maintain a systematic, coordinated infection control process to identify and reduce the risks for
acquisition and transmission of infectious agents among patients, students, volunteers, licensed
independent practitioners (LIPs), visitors, and staff at the ASC. This is accomplished by:

Education on methods for recognition and control of infections

Surveillance of surgical site infections in patients undergoing surgical procedures at the
ASC

Performance improvement efforts to develop initiatives to improve infection related
clinical outcomes and/or infection prevention processes

Design of infection prevention strategies to improve organizational compliance with
regulatory standards
RISK ASSESSMENT
[Briefly describe the patient risk factors and geographic location risks.]
Annually, an assessment considering the geographic location and community environment of the
ASC’s program/services provided and the characteristics of the population served is conducted.
Based in Oregon’s largest metropolitan area and located near an international airport and
international shipping port, the ASC provides care to a large immigrant, indigent, homeless, and IV
drug using population who are at risk for infections such as HIV, TB, Hepatitis A, B, and C, and
emerging pathogens. The Portland area also has several mass transit systems that may be a target
of bioterrorism. Patients who are nursing home residents, diabetics, obese, smoke or use IV drugs
may also carry or acquire organisms such as C. difficile or drug resistant organisms such as VRE,
MRSA, or ESBLs. These patients are also at risk of acquiring surgical site infections. The assessed
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risks, prioritized scoring, and strategies to minimize, reduce, or eliminate the infection risks are
attached in the 2011 Annual Infection Prevention Program’s Risk Assessment and Program Goals.
SERVICES
To minimize risks associated with transmission of infectious agents, the identified scope of
services the Infection Prevention Program (IPP) provides its customers includes:

Conducting surveillance for healthcare acquired infections, antibiotic resistant pathogens
and infectious disease outbreaks

Developing and implementing isolation precautions appropriate for the ASC’s physical
environment and patient population based on national infection control guidelines,
recommendations, and the IPP’s risk assessment

Initiating investigations of patient, student, LIP, volunteer, and employee illnesses or
exposures to communicable diseases

Reviewing aseptic practices including cleaning, disinfection, and sterilization procedures to
ensure they follow national published guidelines based on the ASC’s risk assessment

Developing and annually reviewing facility-wide infection control policies (the Infection
Control Manual) adapted from the CDC, SHEA, AORN, OSHA, and APIC guidelines and other
professional evidence based guidelines

Serving as an infection control resource and consultant

Orienting and educating all employees, medical staff, health care practitioners with ASC
privileges, and volunteers on the cause, transmission, and prevention of infections to
ensure a safe environment for patients, visitors, students, volunteers, and staff

Participation in QAPI projects as they relate to infection prevention opportunities

Participating in the review of policy and procedures to ensure CDC, APIC, and other
evidence-based infection prevention practices are incorporated into policy and practices as
appropriate

Participating in planning for construction and renovation at the ASC so that construction
risks to patients will be minimized

Reviewing hazardous waste management and disposal throughout the facility

Developing policies and processes for employee, medical staff, volunteer and student
immunizations, screening, and exposure follow-up

Developing disease management policies for potential bioterrorist actions according to the
county and state health department recommendations

Collaborating with facilities management contacts in planning, monitoring and designing
the operation of buildings and systems

Ensuring an ongoing state of regulatory compliance
ANNUAL PLANNING
Based on the findings of the annual risk assessment and prioritization of those risks, the review of
surveillance and key performance measurements and outcomes performed annually for purposes of
monitoring and evaluating the effectiveness and impact of the Infection Prevention and Control Plan,
and an assessment of available Infection Prevention Program Resources, the IPP proposes strategies
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to minimize, reduce, or eliminate the prioritized risks. These strategies may be in the form of
policies, process improvement teams, quality control activity, or communication with the ICC or
staff. The program risk assessment, goals and priorities, and surveillance plans are developed in
collaboration with key facility leaders, LIPs, and staff. They are then reviewed and approved for
implementation by the multi-disciplinary [insert name of committee] committee responsible for
investigating, controlling and preventing infection in the facility.
DATA MANAGEMENT & ANALYSIS
Based on the annual approved surveillance plan, surveillance will be conducted to actively identify
infections that may have been related to procedures performed at the ASC. The ASC conducts
surveillance by [Note: describe your surveillance system (i.e., sends emails to patients after
discharge asking if they developed a post-operative infection, or the ASC follows-up with the
physician performing the procedure to obtain this information at a follow-up visit after discharge
and asks them to report it to the ASC]. The ASC maintains supporting documentation confirming
this tracking activity [describe how you maintain the records].
CDC definitions of healthcare-associated infections will be used in the IPP’s surgical infection
surveillance process, which follows the surveillance strategies outlined by the National Healthcare
Safety Network (NHSN). When available, thresholds for surveillance data are established after
review and analysis of current research literature, national norms, and region/community specific
trends. If benchmarks are unavailable, comparison of the ASC’s rates over time shall be evaluated
and improved performance thresholds established.
REPORTING STRUCTURE & RESPONSIBILITIES
Surveillance data analysis is initially performed by the Infection Preventionist and is then reviewed
by the ICC for further interpretation and input. Data analysis results are then distributed to the
governing body for further input. Infection prevention surveillance reports and opportunities for
improvement are shared with the employees, medical staff and ASC health professionals during
update meetings.
The multi-disciplinary group overseeing the Infection Prevention Program is responsible for:

Risk assessment, program planning, regulatory compliance, and goal setting

Activities and decisions related to the prevention of infections, including performance
improvement initiatives

Review and evaluation of the Employee Health Immunization and Screening Program
compliance rates and bloodborne pathogen and communicable diseases exposures

Evaluation of investigation findings and development of action plans as needed

Development, approval, and implementation of effective infection control policies and
procedures
The multi-disciplinary group overseeing the Infection Prevention Program (IPP) consists of the
following individuals:

List members and their positions
The ICC meetings are documented in the minutes that are approved at each meeting and stored in
the administrator’s office.
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ASC personnel and medical staff members share responsibility in the reporting of isolation cases
and reports of suspected infections or outbreaks of infections to the IPP. There is collaboration
between all staff and LIPs and the IPP to identify any nosocomial infection trends or patterns that
may occur or opportunities for outcome improvement in the control and prevention of
transmission of nosocomial infections. Post-operative infections will be reported to the IPP and to
the Oregon Patient Safety Commission.
Licensed independent practitioners (LIPs) are responsible to report state required reportable
infections to the county of patient residence and to the ASC administrator. If contacted, the IP
program is available to assist with reporting infections to the county health departments.
Local county health departments are available to provide consultation and, if required, assistance
to ASCs should questions or concerns arise related to potential infection, disease management, or
outbreaks.
REFERENCES
Horan, T. C. , Andrus, M., & Dudeck, M. A. (2008). CDC/NHSN Surveillance Definition of HealthcareAssociated Infection and Criteria for Specific Types of Infections in the Acute Care Setting. American
Journal of Infection Control, 36, 309-32. (see Surgical Site Infection definitions)
DISCLAIMER: All data and information provided by the Oregon Patient Safety Commission is for informational purposes
only. The Oregon Patient Safety Commission makes no representations that the patient safety recommendations will
protect you from litigation or regulatory action if the recommendations are followed. The Oregon Patient Safety
Commission is not liable for any errors, omissions, losses, injuries, or damages arising from the use of these
recommendations.
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