Implementing and Managing an Infection Prevention Program

To successfully implement and maintain appropriate infection prevention practices at your facility requires knowledge of proper infection prevention practices, creativity, effective management skills, and contributions from all staff at the facility. When resources are limited, it is important to have an organized supply system to ensure an adequate and reliable stock of essential materials and equipment.

This essay provides guidance on:

How to gain staff and administrative support for improving infection prevention practices and transferring the knowledge and skills necessary for making changes
How to assess current infection prevention practices and make appropriate recommendations for improvement
How to implement the changes necessary to improve infection prevention practices
How to monitor infection prevention practices and address any problems identified
How to evaluate whether infection prevention practices have been improved

Gaining Support for Infection Prevention

To improve infection prevention practices at your facility, you must first identify and bring together the key individuals at the facility who can help plan, implement, and support the recommended changes. The types of individuals will vary depending on the size and type of facility. They may include administrators, service providers, central services staff, housekeeping staff, laboratory technicians, and/or infection control committee members. In addition, if your facility has a community board, a representative should be part of the group to represent the client perspective and to communicate the group's goals to the community.

Including all these types of individuals is important for several reasons:

Infection prevention training can be successful only if the participants have the opportunity and support needed to implement their newly acquired knowledge and skills. Therefore, administrative support is crucial to improving infection prevention practices.
Decisions about infection prevention practices reflect considerations of a variety of factors, including available equipment, personnel, administrative support, and budget. Involving a multifaceted group allows different perspectives to be heard and increases the possibility of gaining valuable input into making realistic decisions for change.
People are often resistant to change--even when change is desired--and this resistance can be a difficult barrier to overcome. Including all levels of staff will help staff feel invested in the process and likely make them more open to change, thus reducing or eliminating obstacles and barriers.

Once the group of key personnel is in place, they should receive a brief overview of the importance of infection prevention and the need to improve infection prevention practices at the facility.

Assessing the Current Status of Infection Prevention

Before implementing a plan to improve infection prevention practices at your facility, you must carefully assess the practices currently being performed. This initial assessment will serve not only to identify areas for improvement, but will also supply baseline information against which to compare findings from subsequent assessments so that you can evaluate the success of your efforts.

A good way to assess infection prevention practices is to observe staff in their daily work and compare their activities with infection prevention "standards," or ideal ways that the practices should be performed.

The "Infection Prevention Assessment Survey" included with this course is one assessment tool you can use to do this. This survey, along with a User's Guide that provides a detailed explanation of each standard, have been optimized for printing. Both documents are also available as text downloads. (To download the survey and user's guide, click on the following files and save them to your hard drive. The files can then be opened in any word processing program: guide.txt and survey.txt)

As you observe infection prevention practices at your facility, use the Infection Prevention Assessment Survey or a similar assessment tool to determine which standards are not being achieved.

In assessing infection prevention practices, you will likely find that some practices were performed properly, some need to be improved, and still others need to be newly instituted. If some of the standards were not achieved, it may be because your facility's protocols for infection prevention differ from the standards, not because staff are performing the practices incorrectly or not at all. Therefore, it will be necessary to review your facility's protocols to see whether they are consistent with the infection prevention standards presented in this training course. Protocols and practices that are consistent with or exceed the standards should be reinforced; protocols and practices that are outdated, not practiced, or practiced improperly should be targeted for change.

Designing a Plan to Improve Infection Prevention Practices

Identifying the True Causes and Solutions for Problems

You should first determine the reasons why the standards are not being met. This is critical to ensuring that changes in practices will actually address the true cause of the problem. For example, if staff do not have access to chlorine for use in decontamination, additional staff training will not improve performance, since the supply problem is the underlying cause of the problem that first needs to be addressed.

The following steps may be taken to help address inappropriate practices and resolve problems:

Step 1: Identify the standards that were not achieved, using the Infection Prevention Assessment Survey or a similar evalution tool.

Step 2: For each standard that was not achieved, identify the cause of the problem. Do this by asking "Why?" until the true cause is determined. For example, if instruments and other items are not being decontaminated, begin by asking staff, "Why was decontamination not performed?" If the answer is, "Because there is no bucket with decontamination solution in the operating theater," ask, "Why is there is no bucket with decontamination solution in the operating room?" If the answer is, "Because there is no liquid or powdered bleach to use to make the solution," this shortage of supplies is the true cause of the problem that should be addressed.

Step 3: Determine practical ways to address the causes identified. It is preferable to find solutions that can be accomplished locally by facility staff rather than relying on district, regional, or national-level administrators. For example, in the situation described above, it is better to address the supply problem locally than to ask the district administrators to increase supplies. The example here shows how one facility was able to address a similar problem.

Example - Using available resources:
In a small municipal hospital in Kenya, staff experienced frequent shortages of the liquid bleach used for instrument processing and housekeeping. Although the site had made requests to the district level, there wasn't enough money available to increase current supplies. During staff discussions, a maintenance worker mentioned that the site also received powdered chlorine for treating the facility's well water. Staff soon found that chlorine left over after treating the water could help meet the facility's other needs. They also found that the powdered chlorine used for the well water was cheaper than the bleach purchased for other clinic uses, so they were able to purchase more chlorine with the same amount of money.

Prioritizing Practices that Need Improvement

Achieving all of the desired standards may be extremely difficult. Therefore, staff should prioritize those areas of infection prevention that are most critical or can be most easily and quickly improved. Once these priority practices have been improved, staff can identify the next set of practices needing the most immediate attention and develop plans for achieving them, and so on, until all of the standards have been achieved.

After reviewing the outcomes of the assessment, discuss how the recommended changes would affect service delivery, budget, administrative systems, and equipment and supply needs. In prioritizing, it is important to determine what kinds of problems are standing in the way of achieving the standards. Such problems fall into two categories:

Those that are within the power of facility management and staff to solve
Those whose solutions require the intervention of a higher level of management, such as district, regional, or headquarters-level administrators

Problems that fall into the first category are likely to be easier to solve and should be considered priorities. Those that fall into the second category are likely to be more difficult to solve and may be frustrating for facility administrators and staff.

When prioritizing practices to address, consider the following:

Are resources needed to improve infection prevention practices? If so, are they currently available or is it possible to obtain them?
If funds are required, will there be allowances in the budget?
Do the current inappropriate practices affect most or many of the services provided at the facility?
Will addressing these practices improve the quality of the services currently provided?
Can improvements be made within the next six months?
Do the anticipated activities fit in with and support other changes and activities that are planned or under way at the facility?

Overcoming Barriers to Implementation

Often, infection prevention standards are not achieved because of one or more of the following reasons:

Misunderstanding of the risks involved. Often staff believe that the incidence of postprocedure infections at their facility or serious infections in their community is low, putting them at low risk of infections in their daily work. Consequently, they feel that the infection prevention practices they are currently performing are adequate--even when they are not--and therefore they do not see the need to spend time, energy, and money to institute new procedures or modify existing ones.
Lack of knowledge of appropriate practices. Every person working at the facility has a role to play in infection prevention. All staff should learn how to apply appropriate infection prevention practices to their everyday duties.
Inadequate supplies, equipment, and space. While this is often one of the greatest obstacles in low-resource settings, it is often overemphasized or used as an excuse for not improving practices. The internationally accepted standards presented in this training course use low-tech approaches that are practical, simple, inexpensive, and utilize locally available supplies. Instituting the appropriate practices has already been successfully done in many low-resource settings.

Your site's implementation plan should address these problems through staff training and strategic planning.

Training

Through training programs, ensure that all staff have a good understanding of:

What tasks they and their coworkers are responsible for. For example, everyone should know who is responsible for making sure that the decontamination solution is prepared properly, that clients are adequately prepared before surgery, and that waste is disposed of in a safe manner.
How to accomplish the tasks they are responsible for. Depending on the type and size of the facility and the amount of new information to be learned, the training may be in the form of on-the-job training, formal in-service training lasting one day or longer, or training at a location other than the facility. On-the-job and in-service training may be the most cost-effective and logical ways to train the largest number of staff.
Why they should perform the tasks in a particular way. Staff are more likely to follow procedures when they know that there is a good reason for performing them in a particular way.

In addition to training, all staff should have access to infection prevention reference materials, such as posters, manuals, or videotapes. Staff who have attended an infection prevention training course can also serve as a good resource by acting as role models and providing gentle reminders when they notice an inappropriate practice. Special attention should be given to ancillary staff, whose duties may put them at great risk of infection and injury, or to staff who are low-literate/nonliterate and therefore may be unable to use text-based training or reference materials.

Inadequate Supplies, Equipment, and Space

It is critical to provide the necessary equipment and supplies so that appropriate infection prevention practices can be implemented. Whenever possible, identify locally available resources and determine how to best use them in the face of limited funds.

A problem often encountered in low-resource settings is the inappropriate use of supplies or available space. It is important to assess whether or not supplies are being used in ways that are most appropriate and cost-effective and, if not, to determine how the money spent on them could be used more appropriately. For example, while an expensive commercial cleaning product may be appropriate for cleaning the floors in the facility, bleach--which is usually much less expensive--is equally effective when mixed with detergent. The money saved could then be used for other supplies that currently may not be affordable.

Implementing the Necessary Changes

Once a plan has been designed, the new practices must be implemented. Motivated staff and administrative support are two key components to successful implementation of appropriate infection prevention practices.

Although supplies and equipment are necessary for performing infection prevention practices, it is the people, more than the materials, that make the difference. Well-trained, interested, and motivated staff--even when they have only limited access to supplies and equipment--are more likely to perform infection prevention practices than are poorly trained, unmotivated staff who work at a facility that has all the latest and most expensive equipment and supplies.

Likewise, administrative support is critical to motivating staff and ensuring that the new practices continue to be performed. To show their commitment to and support for infection prevention, senior-level staff and supervisors can:

Follow appropriate practices themselves
Help ensure that adequate supplies are available
Support others in their efforts to perform their duties in a safe manner by emphasizing the importance of good infection prevention practices, the critical role that each staff member plays, and the rationale for performing the various procedures as indicated
Be willing to investigate and institute steps to correct lapses in appropriate practices
Supervise staff in a manner that provides support, encouragement, and assistance, including recognizing staff for performing well or making improvements, encouraging staff to communicate with their supervisors, and encouraging supervisors to listen to the concerns and suggestions of their staff

Offering staff an opportunity to express their feelings about the changes in practice can provide information about what is working well and what will need more support, time, or a different approach.

As staff attempt to improve infection prevention practices, keep in mind that:

Change is a process, not an event that happens all at once.
Some people are likely to be resistant to change.
Take small steps forward, and do not get discouraged if there are a few small steps backward.
Help people work through and adjust to the new practices. Be supportive, not critical.
Be a good role model. Start with yourself--do not expect others to do things you do not do yourself.

Monitoring and Evaluating Infection Prevention Practices

Once infection prevention practices have been implemented, they must be monitored and evaluated regularly to measure the overall success of your efforts to improve practices. Monitoring and evaluation may take several forms.

You can informally monitor the staff's practices on an ongoing basis by observing them as they perform their daily routines. Using a facilitative approach--one that emphasizes mentoring, joint problem-solving, and two-way communication between the supervisor and staff--is likely to yield the best results. Staff can also provide informal monitoring by giving reminders and encouragement to their coworkers. (EngenderHealth papers and books on facilitative supervision and other aspects of service management can be ordered on the EngenderHealth publications page.)

A follow-up evaluation should be scheduled to see how well the participants are using the new skills, to identify performance gaps that may still exist, and to plan for additional training or on-the-job reinforcement, if needed.

More formal approaches include an annual management assessment using the Infection Prevention Assessment Survey and a staff self-assessment. After conducting an initial assessment of infection prevention practices at your facility using the Infection Prevention Assessment Survey, the survey should be conducted annually (preferably, in the final quarter of the year) to compare the results with those from the previous assessment. Applying the survey results should be a collaborative process, involving staff in gathering data, discussing the findings, and identifying problems or gaps. Staff may conduct a self-assessment two to four times per year using EngenderHealth's COPE approach or another quality-improvement exercise.

Supervisors at various levels can use the results of evaluation measures as follows:

Facility supervisors can:

Identify problems and provide an opportunity for improvement
Determine training needs
Measure progress in improving quality from one year to the next
Involve staff in measuring progress and identifying the causes of problems
Report on infection prevention practices at the facility

District or regional supervisors can:

Assist facility supervisors in planning and prioritizing technical assistance and training
Measure progress at the facility level and, to some degree, the support received and needed from the supervisory system
Identify successes, gaps, and problems that exist systemwide by analyzing results from all of the facilities in one district or region and develop an implementation plan to address the problems or refer them for national-level consideration
Discuss and coordinate with supervisors at the district or regional level
Report on infection prevention practices in the district or region

National-level supervisors can:

Assist district or regional supervisors in identifying systemwide successes, gaps, and problems
Measure progress at the facility, district, regional, and national levels
Respond to specific needs identified on a priority basis
Report on infection prevention practices in the nation
Report on progress in improving service quality

When using the information gathered from the Infection Prevention Assessment Survey, it is important to remember that the survey provides only a snapshot of what happened on a given day at a particular place, not an indication of general infection prevention trends at the facility. The survey is meant to help determine whether or not practices have changed for the better: caution should be taken not to generalize the results.

To continue involving the staff in infection prevention efforts, it may be useful to share with them the results of the previous year's and current year's assessments so they can see what changed--that is, learn which standards that had not been achieved the year before were achieved this year, and vice versa. Once all of the practices have been reviewed, the staff can discuss why they think certain practices improved or worsened and help problem-solve to change practices that need improvement.

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