The Road to Excellence: Paving the Way to Construct a Successful Infection Prevention Program in a Complex Healthcare Network

BACKGROUND: Our healthcare system is a level I trauma center with 25 clinics and over 1 million patient encounters per year. The Infection Prevention team of 9 has oversight of all infection prevention activities. A mock survey was completed to prepare the system for a Joint Commission survey. Results from the mock survey identified gaps within the infection prevention program and called attention to the need to implement best practices. During this time, the infection prevention team was experiencing challenges related to the COVID-19 pandemic and high staff turnover. METHODS: Mock survey findings were categorized into 8 buckets: Infection prevention program, dust and environmental cleaning, expiration dates, manufacturer's instructions for use, low level disinfection, probes, scopes, and storage of supplies. Infection Preventionists were assigned to service lines and buckets to facilitate interdepartmental collaboration and create solutions to address findings. Routine tracers completed by the infection prevention team provided a means to measure compliance over time. RESULTS: The mock survey was conducted in November 2020 and the Joint Commission survey was completed in November 2021. In just 12 months, there was a 98% reduction in the number of findings attributed to the Infection Control chapter - 168 mock survey findings in 2020 was reduced to 2 survey findings in 2021. In 2020, 127 findings were considered high risk and 33 were considered an immediate threat to health and safety. There were 0 findings in 2021 that were considered high risk or an immediate threat to health and safety. CONCLUSIONS: Implementation of a robust infection prevention program is essential to the success of the healthcare system. Key elements that contribute to a high-quality program include standardization of best practices, designating team members to become consultants for service lines, increasing interaction and visibility with staff members, and implementing committees to discuss opportunities for improvement and monitor initiatives.