national corporate infection prevention program...

National Corporate Infection Prevention

Program SurveyJuly 2016

Pediatric-2; Psychiatric -3; Eye-1

T o ta l Ave ra g e Ra ng e173 11.5 1-3819 1.2 1-528 1.8 1-1380 5.3 0-2043 3.0 0-6

1791 162.8 2-45025 1.6 0-5

3625 258.9 5-100057333 4777.5 221-10000412194 29442.0 620-189302

17 1.1 0-414 1.0 0-431 2.0 0-656 3.7 0-13

# Specialty hospitals (e.g.OB, # LTAC or acute rehab units# Ambulatory Surgery Centers

# Academic Teaching hospitals# Ambulatory centers/clinics# Employed providers# Employees# Critical Access Hospitals

Total Number of hosptials in your # Hospital greater than 500 beds# Hospital 350-500 beds# Hospital 100-350 beds# Hospital less than 100Total ICU beds

De scrib e yo ur sys te m (15 re sp o nse s)Answe r Op tio ns

Q1: Describe your system

Q1: Describe your system sorted by bed size

Hospital #Total Number of hosptials in your system

# Hospital greater than 500 beds

# Hospital 350-500 beds

# Hospital 100-350 beds

# Hospital less than 100

Total ICU beds

# Academic Teaching hospitals

# Ambulatory centers/clinics

# Employed providers

# Employees

What is range of licensed acute care beds? (e.g. 60 to 450)

# Critical Access Hospitals

# Specialty hospitals (e.g.OB, Oncology, Pediatric)

# LTAC or acute rehab units

# Ambulatory Surgery Centers

14 38 5 13 20 0 200 0 638 18652 189302 100 to 600 0 0 2 131 20 1 2 12 5 1 62 10000 31901 10 to 500 1 2 26 19 1 1 9 8 1 260 5000 23400 25-515 3 0 0 72 13 1 1 5 6 182 1 86 6000 27500 32 to 668 2 1 2 29 13 1 0 4 6 165 1 288 387 8671 2 2 2 2

10 12 2 1 8 1 301 3 400 6300 35000 125-750 1 1 4 613 12 1 2 6 3 450 2 150 4000 27000 35 to 1315 1 1 6 415 10 1 0 3 6 195 1 126 673 6800 50-450 3 2 3 6

4 8 1 1 3 3 1 1 6 05 6 2 2 2 0 2 1000 10,000 200-10207 6 2 0 3 45 2 260 12000 0 1 2 48 6 1 1 0 4 95 1 120 2000 25000 50-600 4 0 1 5

11 5 0 3 2 0 93 5 100 2000 5000 470 0 0 0 13 4 0 1 3 0 63 4 130 2100 10000 123 to 354 0 4 1 4

12 1 0 0 0 1 2 0 5 221 620 25 1 0 0 0

• Transplant, dialysis, trauma care• Transplant, burn, dialysis in one major facility, dialysis in multiple

facilities• Cardiac, transplant, dialysis, burn oncology• burn, dialysis, joint replacements, cardiac, stroke center• Level 1 Trauma, Burn, Neuro, PICU, Dialysis• Solid organ, BMT, dialysis• dialysis (chronic & acute), solid organ transplant, BMT,NICU 1B,

Trauma, burn center, comprehensive cancer center, CF, • Transplant, Trauma, Dialysis, Fetal Surgery, Neurosurgery

Q2: What other services?

Q3:Describe your Hospital System

Located in California, Washington, Oregon, HawaiiOne region has IP Director

Re sp o nse Pe rce nt

Re sp o nse Co unt

69.2% 90.0% 046.2% 623.1% 315.4% 2

3

Answe r Op tio ns

Regions have formal IP leaders

Concentrated within 10 mile radius

Are yo ur ho sp ita ls :

Organized by Regions

Multi State

Other (please specify)

Located within a day's drive to corporate or regional

Q4: IP Travel Time for off campus

Wha t is a ve ra g e tra ve l time fo r IP to a nd fro m c linic /a mb ula to ry ce nte r?

Ho w ma ny mile s e s tima te d to "o ff s ite " lo ca tio ns fo r e a ch IP?

co mme nts

30 60 miles45 25 miles30 25 miles60 20 miles

85 66 miles (For one facility, Tot miles/ year=4600 and 5986 minutes/ year travel time

60 20 miles60 75 miles30 20 miles60 60 miles one site is 4 hours round trip

25 45 miles20 10 miles

60 20 mileshospital level IP = 20 square miles, ambulatory regions = 100 square miles

120 10 miles54 average

• I was recently asked to assume some oversight over Employee Health but I am very reluctant to agree. Emp Health is an HR function. HR and Workman's Comp drive that group so they don't have any clinical support or oversight. While clinical support is needed, my plate if already full.

• CIC strongly encouraged but not required at this time• Four states, only one state has IP Director at this time

Q5: Describe your system roleAnswe r Op tio ns


Re sp o nse Co unt

T he re is a fo rma l a utho rity s truc ture to se t sys te m g o a ls , p rio ritie s a nd s tra te g ie s .

86.7% 13

Syste m wid e le a d e rship g ro up tha t re v ie ws Infe c tio n Pre ve ntio n HAI p e rfo rma nce .

86.7% 13

Syste m wid e s truc ture (d ire c t re p o rting ) o r co nsulta tive /co o rd ina ting (d o tte d line )

80.0% 12

Re p re se nt yo ur sys te m with e xte rna l a g e nc ie s o r p ro fe ss io na l o rg a niza tio ns?

80.0% 12

Pre se nt o n IP to p ics with e xte rna l a ud ie nce s? i.e . APIC lo ca l me e ting , Clinica l wo rksho p s, Na tio na l APIC, SHEA, IDSA

60.0% 9

Syste m wid e le a d e rship g ro up re v ie ws Infe c tio n Pre ve ntio n & Co ntro l a c tiv itie s a nd p la n.

60.0% 9

Syste m wid e le a d e rship g ro up tha t re v ie ws a nd p ro v id e s o ve rs ig ht fo r IP re g ula to ry co mp lia nce .

60.0% 9

Do e s yo ur p o s itio n re q uire CIC ce rtifica tio n?60.0% 9

Yo ur ro le is p rima rily a d v iso ry , co nsulta tive a nd tra ining .

53.3% 8

Do yo u re g ula rly a ud it lo ca l o r re g io na l p e rfo rma nce ?46.7% 7

Do yo u ha ve a re g io na l s truc ture ? 26.7% 4Re sp o ns ib le fo r Emp lo ye e He a lth Se rv ice s? 6.7% 1Othe r 3

Q6: More about you:By title (s ), to who m d o yo u re p o rt to ? (e .g . CMO, VP Qua lity , VP Sha re d Se rv ice s)

Ho w ma ny ye a rs o f IP

re la te d e xp e rie nce ?

Wha t is yo ur hig he st le ve l o f e d uca tio n?

Wha t is yo ur b a ckg ro und b e fo re e nte ring IP wo rk?

Director of Infection Prevention, report to Executive Director of Clinical Practice 17 Masters Critical Care NurseVP Quality 7 MPH Quality and RiskChief Quality Officer 25 PhD Microbiology & Publich Health Administrative Director of System Quality who reports directly to CMO 7 Bachelors

accounting industry then medical-surgical nursing

VP Medical Affairs 25 MS MicrobiologyCorp. Associate VP, Clinical Operations 8 MSN

Accreditation, Clinical Standards, Regulatory Compliance, CIS, OB

VP Quality 20 MS x2 MicrobiologyChief Quality Officer, System Innovation Officer 20 MS Clinical LaboratoryVP of Quality 5 BSN 11 years, Department of Health VP Safety 13 MPH Critical Care

CMO 17 dual mastersRN, home infusion, PICC nurse, home health

Director of Quality, Risk, Infection Prevention 3 Some graduate work Public HealthDirector of Patient Safety and Quality 13 Master's

Undergraduate biology/psychology

National Medical Director Patient Safety and Risk management 28 BSN

nursing supervisor, nursing manager

VP Quality, CMO 18 Master's Degree NICU RN, Chief Quality Officer

Q7: Tell us about your corporate staffing structure

Ho sp ita l ID

T o ta l Numb e r o f Ho sp ita ls

T o ta l FT Es inc lud ing yo urse lf

Ho w ma ny IP FT Es

Ho w ma ny d a ta

a na lys ts FT Es

Imp ro ve ment a d v iso rs

(no t IP) FT Es

Pro je c t Ma na g e r (no t IP) FT Es

Phys ic ia n FT Es

14 38 1 1

support but no dedicated

FTE 0 0 01 20 35 26 1 2 0 126 19 1 1 0 0 0 02 13 5.5 1 4 0.1 0 0.19 13 1 1 0 0 0 0

10 12 1 30 0 0 0 113 12 4 3 0 0 0 0.515 10 1 0 1 0.25 0.25 0.25

4 8 0.6 0.4 0.2 0 0 05 6 2.6 1 0.2 0 0 0.67 6 10 10 0 0 0 08 6 1 0 2 5 5 1

11 5 8 6 2 0 00.8 of one and 0.2 of

another3 4 10 8 0 0 0 1

12 1 1 1 0 0 0 0

Q8: Tell us about your staffing structure at local hospitals

Hospital ID

Number of hosptials IP FTEsHow many are

part time?

Support or Other

FTEs (analyst, clerical)

How many other support are part

time?

How many Physician FTEs or average hours per

month14 38 3 0 1 0 01 20 1 46 19 25 1 6 1 02 13 18 3 4 0 209 13 16 0 0 0 0

10 12 2 2 0 0 013 12 27 2 015 10 8 4 1 1 14 8 10 5 0 0 45 67 6 10 0 2 0 08 6 13 2 1 1 1

11 5 8 0 2 0 13 4 8 1 1 0 1

12 1 1 1 0 0 0

Q9: Centralized work previously done by local sites?

Answe r Op tio nsRe sp o nse

Pe rce ntRe sp o nse

Co untSyste m wid e inte rna l re p o rting o r d a shb o a rd s 92.9% 13Po licy a nd p ro ce d ure s 85.7% 12Pro d uct se le c tio n o r a d v is ing with sup p ly cha in 78.6% 11Cha ng e s to EHR to ha rd wire p ra c tice s 78.6% 11Sta ff e d uca tio n co nte nt d e ve lo p me nt fo r o nline le a rning

64.3% 9

Ad minis tra tio n o f d a ta mining sys te m 64.3% 9Syste m wid e e me rg e ncy p la nning 57.1% 8Ma nd a te d re p o rting to NHSN 50.0% 7Ma nd a te d Sta te re p o rting ( a d d itio n to NHSN) 50.0% 7Co o rd ina tio n with o the r c linica l a re a s fo r imp ro ve me nt p rio ritie s

50.0% 7

Syste m le ve l fa c il itie s d e s ig n 35.7% 5Inte g ra te with sys te m Pe rfo rma nce Imp ro ve me nt 35.7% 5Da ily surve il la nce a t co rp o ra te o r re g io na l 28.6% 4Othe r (p le a se sp e c ify ) 14.3% 2

Other: Working with supply chain to standardize products/devices.Not applicable to my system

Q10: How do you impact local/site program and performance?



Co untMe a sure me nt, d a shb o a rd s 100.0% 14Pro v id e IP e d uca tio n 92.9% 13Syste m le ve l p o lic ie s a nd g uid e line s 92.9% 13Fa c ilita te Syste m wid e me e ting 85.7% 12

Aud iting /Ob se rva tio n78.6% 11

Se le ct imp ro ve me nt ta rg e ts 78.6% 11Id e ntify imp ro ve me nt ta c tics o r d rive rs 71.4% 10Sta nd a rd ize IP wo rk p ra c tice s o r wo rk p ro ce sse s 64.3% 9Onb o a rd ing a nd me nto ring ne w IPs 64.3% 9De sig n o rie nta tio n a nd o nb o a rd ing 50.0% 7Co mp e te nc ie s initia l a nd o ng o ing 50.0% 7De ve lo p jo b d e scrip tio ns o r jo b fa milie s 42.9% 6Wha t e lse ? 4

• Accreditation/regulatory readiness auditing • Annual Risk assessment • Some onboarding occurs but no formal program for orientation, initial or ongoing competency validation. Tremendous mentoring provided

but no formal onboarding program which is desperately needed. The reason that such a program has not yet been developed is that as the Corp IP with no resources, there is not time to devote to the development an orientation/competency program.

• Developing IP program and measures for ambulatory and clinics.

Q11: How do you share performance across the system?



Co untSyste m sco re ca rd o r d a shb o a rd 86.7% 13

Co mb ina tio n o f me a sure s66.7% 10

Inc lud e o ur p ro ce ss me a sure s 46.7% 7One p a g e mo nthly re p o rt p e r HAI o r 33.3% 5Mo nthly Ha rm Ind e x 26.7% 4Mo nthly SIR o nly 20.0% 3Wha t e lse ? 20.0% 3Mo nthly Ra te s o nly 6.7% 1

• Board Report • We report actual numbers for all HAI's and SIRs. The SIRs can be very misleading and often give an

inaccurate impression of reality. For example, one large facility had 57 cases of C.diff reported but because the SIR for that timeframe was 0.78, senior leaders were left feeling "all is well".

• Not applicable to my system

Q12: How do you assure EBP are consistently implmeneted?• Via nurse practice councils

• Policy implementation checklists or gap analysis

• Practices are standardized throughout the system

• Goal is to identify a standard process measure for all objective outcome measures and have random auditing

• We are working to implement evidence-based bundles for C.diff, CAUTI, CLABSI and Hip & Knee SSI reduction

• currently up to each site

• Review at monthly IP meetings; Rounding• System Audits-Key result areas

• observations, monitoring and education• It is the responsibility of corporate staff to stay current with recommendations, guidelines, and new

evidence. This information is then passed on to the IP hospital staff during our monthly meetings. Additionally, we have an evidence-based care team at the system level that completes in-depth reviews upon our request.

• regional IP leader site visits

• observation, purchasing history, policy/procedure

Q12: Assess regulatory/accreditation readiness?

• Partner with regulatory colleagues and utilize readiness checklists

• Mock surveys

• Standardized practices system wide

• On site and consultative

• Attempt to visit as many hospitals as possible prior to survey year. Very often this is not possible and only those facilities at greater risk for findings receive a visit. We do discuss survey prep ongoing as a routine item at face to face meetings and during monthly calls.

• Currently up to each site

• Regularly scheduled rounding

• Annual survey-DNV accreditation

• Observations, monitoring and education

• Readiness plans are shared across facilities. Additionally, sites share their experiences in detail post-visit. Corporate staff are available upon request from the hospital to assist with assessment and auditing.

• Regional IP leader site visits

• semi-annual mock surveys coordinated by corporate IP

Q12:Handle emerging or urgent issues?• Bring system IP team together with internal subject matter experts

• System coordination of response

• Centralized process for policy development, training, and implementation

• Depending on priority of issue, will pull together a system team to go on site to all facilities

• Communication via email and discussion on monthly calls.

• Centralized functional integration team for IP

• System wide conference calls; Email blasts

• Through Safety department-Alerts

• Drop everything and addresses

• If it is an issue that affects all of our facilities, corporate IP takes the lead. We are responsible for disseminating information, training and education. Local IP staff assist as needed.

• Convene multi disciplinary task force

• Corp IP takes lead, coordinates with local IPs and stakeholders.

Q13: What is your data mining system?



Co untOthe r (p le a se sp e c ify ) 46.7% 7EPIC ICON mo d ule 40.0% 6T he ra d o c 26.7% 4Me d mine 20.0% 3Pre mie r Sa fe ty Surve il lo r 13.3% 2VECNA Qua lity Co mp a ss Pa thfind e r 13.3% 2Ho me g ro wn so lutio n 6.7% 1Othe r 6.7% 1RL So lutio ns 0.0% 0Se ntri7 0.0% 0ICNe t 0.0% 0No ne 0.0% 0

• We are in process of transitioning to EPIC, only 1/8 facilities are currently up on ICON• Soon centralizing to one system across enterprise• In the process of converting from Safety Surveillor to TheraDoc• Clarity• Transitioning to EPIC ICON 2017-2018• MedMined

Q14: Hospital HE/Physician leaderAnswe r Op tio ns


Re sp o nse Co unt

Do yo ur HOSPIT AL IP p ro g ra ms ha ve d e s ig na te d MD p a rtne r?

86.7% 13

Do yo u ha ve a co rp o ra te le ve l MD p a rtne r fo r yo ur co rp o ra te IP p ro g ra m?

60.0% 9

Is the HOSPIT AL IP MD p a rtne r a n Infe c tio us D ise a se sp e c ia lis t?

60.0% 9

Do yo u ha ve a s ta nd a rd jo b d e scrip tio n fo r HOSPIT AL IP p a rtne r MD?

46.7% 7

Do e s the Co rp o ra te MD co lla b o ra te with ho sp ita l MD p a rtne rs?

40.0% 6

Do e s the MD re ce ive initia l a nd o ng o ing tra ining in Inf Pre ve ntio n, Co ntro l, Ep id e mio lo g y?

40.0% 6

Is the re a d e d ica te d FT E fo r HOSPIT AL MD? 33.3% 5Do yo u ha ve a s ta nd a rd jo b d e scrip tio n fo r CORPORAT E IP p a rtne r MD?

33.3% 5

Othe r (p le a se sp e c ify ) 5

• ID Medical Directors are contracted for designated amount if hours each month• Medical Director contracts are same language• N/A• We have very few ID physicians system wide as not every site has an ID trained physician. All hospitals have a physician chair

the ICC but I am not confident that every IC chair has received special training even though that is required in California.

• Developing standard position description

Q15& 16: Physician Staffing

• No• No• 1• Unknown• 0.6• 2 lead MDs from 2 largest hospitals

serve as co-leads for system• We do not have an FTE for the

Corporate MD. That position is a contracted position and the contract must be renewed each year.

• 0• 0.8• 0.5• no• 0.05

Dedicated FTE for Corporate MD?

• Five to ten hours per week• Administrative time dedicated 20

hours/month• 20 hours per week• Unknown• 4• No• Quarterly stipend 0.25 FTE• No• No• n/a• local ID physicians are paid on a contracted

for 10-40hours per month

If Administrative time, how much?

Q17 & 18: Additional information

• NA• No• weekly• Not at this time• daily• weekly meeting with MD at their primary site

- the largest 2 hospitals - and monthly meeting with system functional integration team

• Yes, quarterly IP meetings at a minimum and as the need arises

• no• yes bi monthly• No. But is present for our monthly group

meeting.• n/a• Corporate MD meets monthly with IP team.

Meet regularly with IP team?• They report to Vice President of Medical

Affairs and no designated training programs are in place or required

• SHEA• SHEA hospital epidemiology training

course, CDC, MPH training• Unknown• Infection Prevention Fellowship• SHEA, IDSA, State ID Organization

• SHEA, Infectious Disease Society and other physician groups

• local conferences, IDAC, IDSA, SHEA• Corporate MD: SHEA

Hospital MD: N/A not required per their contracts

• n/a• SHEA programs

What is source of initial/ongoing Training?

Did we miss something?• This system is more of a hybrid model and my role as a director is for one region which is seven hospitals and

fifty outpatient locations. The IPs and one epidemiologist report to me. I serve as a faciliatator and consultant to the other thirteen hospitals. We are trying to standardize and centralize but it will take some time.

• N/A

• My hospital system has only invested in my role/system director role within the last year and at this time, it is only 0.4 FTE. I suspect with continued opportunities for value added with this role, it will become full time within 1-2 years.

• Q4: How many miles estimated to "off site" locations for each IP? Consider adding "miles per week, month or year".Consider combining Q15 & Q16 with Q14: First box under Q14: Do you have a corp level MD partner for your corp IP program? Next box under that: Is there a dedicated FTE for your corp MD? If so, what number of FTEs? Next box under that: Is the MD partner provided admin time in lieu of dedicated FTE and if so, how much time (hrs/week)?

• We are not fully integrated - so responses reflect that we are in process. We have one centralized IP Integration team that is moving us in this direction, however, their lacks a system matrix leadership that creates some lack of clarity on IP authority and accountability across sites vs. at a single site for some IP focused work. I think you may find some confusion with # FTE questions and clarifying with # of people first and then FTEs, part-time etc.would be more clear.

• Academic medical center has clerical and analyst support.Physician dedicated FTE = 20 hours/month/facility

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