Using the Organizational Infection Risk Assessment to Energize Your Infection Prevention Program Terrie B. Lee, RN, MS, MPH, CIC Director, Infection Prevention & Employee Health Charleston Area Medical Center Charleston, WV Organizational Infection Risk Assessment • Part of infection prevention and control planning process • Serves as the starting point of a well-developed plan • Together with the Infection Prevention plan, forms the foundation of program • Assists in focusing surveillance and other program activities • Meets regulatory requirements Infection Risk Assessment Regulatory Influence • Identify risks for acquiring and transmitting infections based on:    Geographic location, community, and population served Care, treatment, and services provided Analysis of surveillance activities and other infection control data • Risks identified annually and when significant changes occur Infection Risk Assessment Regulatory Influence • Risk assessment occurs with interdisciplinary input:      Infection prevention personnel Medical staff Nursing Leadership Others • Prioritize and document risks Risk Assessment Process • Homework and Planning  Forms Preliminary completion of organization evaluation form Preparation of risk assessment form  Standards  Reports, Surveillance data  Knowledge of current issues Risk Assessment Process • Team Recruitment  Invitation  Solicit information in advance What are the most important infection prevention and control problems? What are our most frequent reasons for admission, procedures performed, etc. Risk Assessment Team • Infection Prevention staff • Nursing • Medical Staff • Laboratory • Pharmacy • Quality/Performance Improvement/Safety • Ambulatory Care • Surgery • Housekeeping • Maintenance/Facilities • Employee Health • Administration • Central Processing • Accreditation Coordinator Risk Assessment Meeting • Commitment for attendance/ participation • Time for thought and discussion • Prioritizing risks • Determining Infection Prevention Plan Organization Evaluation • Factors to include  Geographic and environmental  Population characteristics  Area endemic infections  Other area-related risks  Medical care characteristics  Services provided Organization Evaluation • Description of factors • Characteristics that increase risk for infection • Characteristics that decrease risk for infection • Get input at meeting for final completion of form • Include findings in risk assessment Risk Assessment • The group work begins! Risk Groups • Antibiotic-resistant organisms • Failure of prevention activities • Isolation activities • Policy & procedure • Preparedness • HAIs • Environment • Employee Health • Other Assigning Three Values to Each Risk • Probability of event occurring • Impact/severity • Current systems Things to Consider for Probability • Known risks • Historical data • Reports in literature Things to Consider for Impact • Threat to life and/or health • Disruption of services • Loss of function • Loss of community trust • Financial/legal impact • Regulatory impact • Standards/requirements Things to Consider for Current Systems/ Preparedness • Current policy & procedure • Implementation of plans • Training status • Measures of outcome or process • Availability of backup systems How to Assign Values • There are no right or wrong answers! • Allow discussion • Push group for consensus • Keep group focused, on target • Important to be consistent • Go through entire list of risks • Assign someone to calculate risk scores Risk Score • Derived from multiplication of three component numbers • Group consensus vs. mathematical averaging or summation Setting Priorities • Rank order risks using risk scores • Each organization’s priorities will be different Risk Assessment Exercise • Discuss each potential risk • Come to group consensus on assignment of number for each component • Multiply component numbers to calculate risk scores • Occasionally compare risk scores to validate with group From Risk Assessment to Infection Prevention and Control Plan • Written infection prevention plan • Goals • Measureable objectives • Strategies for implementation Infection Prevention and Control Progress Report • Priority • Goal • Objectives • Strategies • Evaluation Method • Current Status/ Evaluation/ Next Steps Infection Prevention and Control Progress Report • Priority - From Risk Assessment • Goal - To address each priority • Objectives - To achieve each goal • Strategies - To achieve each objective • Evaluation Method – For each objective • Current Status/ Evaluation/ Next Steps – How are we doing? Example of Goal & Objective Assessment: 62% of personnel wash hands or use alcohol hand rub during direct patient care activities. Goal: Increase use of hand hygiene. Objective: Increase use of hand hygiene by direct care providers on 3 North by 40% in the next 6 months. Infection Prevention Progress Report Exercise • For your top three identified risks, develop  a goal,  one or more objectives,  strategies for achieving those objectives  methods of evaluation Tips For Developing Written Plan • Develop outline of Infection Prevention and Control program • Draft Table of Contents • Network with others • Consider incorporating your plan into your annual report Plan Tips, Continued • Demonstrate collaboration throughout plan  Leaders, managers, caregivers & others  Collaborate in program development, implementation, evaluation, and assessment of resources • Assign responsibility for annual review • Include the essential elements • Distribute your plan widely Benefits of Risk Assessment Meeting • Spreading the knowledge of the scope of what you “do” • Getting buy-in from key organizational stakeholders • No individuals to blame for priorities - organizational decisions • Many people able to articulate how IP plan was created Summary • Each organization can conduct an infection risk assessment that is unique to itself. This risk assessment is used to set priorities for the infection prevention program • Once priorities are identified, goals, objectives, and strategies help to create the organizational infection prevention plan • The risk assessment process is ongoing, with a focused revision taking place annually • A progress report can be used to track and report priorities and accomplishments of the infection prevention program Any Questions? Contact Information Terrie B. Lee, RN, MS, MPH, CIC Director, Infection Prevention & Employee Health Charleston Area Medical Center 3200 MacCorkle Ave.,SE Charleston, WV 25304 304-388-4259 [email protected]