Using the Organizational Infection Risk Assessment to Energize Your Infection Prevention Program

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
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
• 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
• Prioritize and document risks
Risk Assessment Process
• Homework and Planning
 Forms
Preliminary completion of
organization evaluation
Preparation of risk assessment
 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
What are our most frequent reasons for admission, procedures
performed, etc.
Risk Assessment Team
• Infection Prevention staff
• Nursing
• Medical Staff
• Laboratory
• Pharmacy
• Quality/Performance
• 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/
• 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
• 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
• 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
• 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
• 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
[email protected]