Abstract :
BACKGROUND/PURPOSE: This health system was developed from the integration of five health services including 17 healthcare facilities with a combined 364 hospital beds (range 6–113). The unique challenges for this infection prevention program include the geographical size (23000 km2), population (135,450), number of locations, diversity of services, the short length of stay, innovative sustainability, and the standardization of data collection for healthcare-associated infection with an accurate baseline data for performance measure. The infection prevention program will support healthcare facilities, make an impact on high risk/target areas, raise awareness in the community, support clinical practice improvements, and develop effective surveillance systems. Program principles are to manage risk effectively, establish safe systems, and protect patients, healthcare workers, and visitors. An evidence-based approach will be used where possible. The program will be cost effective and customer focused. The program is strongly supported by the executive management.
METHODS: An initial orientation and gap analysis questionnaire was completed by visiting all sites. This data, together with national and international program recommendations, was documented. An infection prevention program with risks identified (including action plan) was endorsed by the executive management group.
RESULTS: Utilizing organizational systems, implementation began with communication networks established through e-mails to “infection prevention teams at all sites. An expert infection prevention panel is in progress. Policy standardization (with hyperlinks to Web pages) has been essential in hand hygiene, waste management, endoscopy, cleaning services, and staff immunization. As a resource, infection control manuals are at all sites, and directive outbreak management pack templates are available. The education plan focuses on a safe practice orientation package, self-directed learning packs, e-learning, and other learning opportunities. Standardization of surveillance systems, including multidrug-resistant organisms, is in process. Sentinel events, complaints data, and an incident monitoring and hazard alert are used to identify risk.
CONCLUSION: Effective communication and education systems, with community ownership, strong leadership support, clear structural policies and procedures, and a focus on risk identification and quality management are key components of an ongoing successful program.
