1. Murray, Kathleen DNP, ARNP, NE-BC

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System-wide leadership strategies

Q I've been asked to lead the infection control practitioners across my large healthcare system. I don't have a background in infection control, but I've successfully led other system-wide initiatives. Can you provide strategies for my new leadership role?

The decision to integrate infection control departments across the system is very timely. Healthcare epidemiologists and infection control practitioners are facing increasing scrutiny and pressure to protect patients and healthcare workers from acquiring infections. Mandated public reporting of healthcare-associated infections; The Joint Commission's infection control standards, including the universal precautions National Patient Safety Goal; and news headlines are increasing the visibility of infection control within healthcare.

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Do you have one infectious disease physician group for the system? If yes, then you'll need to meet with the physician leader of the group to discuss your role and potential next steps in moving forward with a system-wide infection control program. If you have several infectious disease physician practices throughout the system, you'll need to meet with each of the physician leaders to garner their support for the system's infection control prevention strategy. In addition, you need to investigate if there are system-wide medical staff rules and regulations in place, as well as one system-wide medical executive committee. If each facility has its own medical staff rules and regulations and medical executive committee, it will be more challenging to get approval for system-wide infection control protocols/policies, electronic health record documentation changes, and technology. The key to successful physician support for the infection prevention strategy will be the system's chief medical officer.


After you've obtained the infectious disease physicians' support, you'll need to establish a system-wide infection control committee, which should consist of a multidisciplinary team whose members include representatives from administration, medical staff, infection control practitioners, pharmacy, laboratory, clinical nurses, safety and security, environmental services, occupational health, risk management, and quality.


With the committee members, you'll need to establish the purpose of the committee, including (1) minimizing the development of hospital-associated infections; (2) preventing and reducing employee exposures to bloodborne pathogens and communicable diseases; and (3) providing education on infection prevention strategies to patients, healthcare providers, and visitors utilizing current research, evidence-based practice, and epidemiologic principles when determining clinical practice as it relates to infection.


In addition, you'll need to define the committee's activities, which should include at a minimum:


* assisting with system-wide decision-making and problem-solving activities related to infection control


* providing infection control expertise for any new service or product being considered for implementation


* monitoring compliance with infection control standards and activities required by state, federal, and other governing agencies


* providing reports and surveillance findings to appropriate system and hospital leadership, committees, and departments


* standardizing infection control procedures throughout the healthcare system.



Next steps include completing a gap analysis by facility regarding the roles and responsibilities of the infection control practitioners, facility-based resources supporting infection control practitioners, pay practices, the facility-based infection control plan, infection control policy and procedures, the infection control reporting structure, and infection control practitioner full-time equivalent allocation by facility. Meet with each epidemiologist/infection control practitioner individually to discuss possibilities and barriers to the system-wide infection control department's integration. You'll need to work with the group and assign responsibilities for key infection prevention strategies, such as policy and procedures, education, department of the health liaison, and committee representation. Establish, at a minimum, a monthly meeting with the infection control practitioners using preplanned agenda items.


Use this opportunity to build a sustainable infrastructure to monitor adverse infection events, prevent the transmission of infections, and promote best practices. Remember to always lead by example, be a team player, develop relationships with key stakeholders, and show that you care.