Foreword

ix

Chapter 1

Setting the Stage: An Introduction   Barbara Moore Soule, R.N., M.P.A., C.I.C.; and Louise Kuhny, R.N., M.P.H., M.B.A., C.I.C.

1

Creating a Comprehensive Infection Prevention and Control Program

1

What the Joint Commission Requires Regarding Infection Prevention and Control

1

Using the APIC/JCR Infection Prevention and Control Workbook

2

Reference

2

Chapter 2

The Infection Prevention and Control Program   Kathleen Meehan Arias, M.S., C.I.C.

3

Managing an Effective Infection Prevention and Control Program

3

Exploring IC.01.01.01

4

Related Standards

13

Summary

14

Further Resources

14

References

15

Chapter 3

The Role of Leadership in Infection Prevention and Control Programs   Russell N. Olmsted, M.P.H., C.I.C; and Barbara Moore Soule, R.N., M.P.A., C.I.C.

17

Leaders Influence the Performance of the Infection Prevention and Control Program

17

Exploring the Leadership Standards Related to Infection Prevention and Control

19

Summary

24

Further Resources

25

References

25

Chapter 4

A Risk-Based Approach to Infection Prevention: Creating an Infection Prevention and Control Plan   Barbara Moore Soule, R.N., M.P.A., C.I. C.

27

Using a Risk-Based Approach to Infection Prevention

27

Exploring IC.01.03-01

28

Critical Steps in Conducting a Risk Assessment

30

Exploring IC.01.04.01

41

Exploring IC.01.05.01

42

Developing an Infection Prevention and Control Plan

45

Summary

47

Further Resources

47

References

48

Chapter 5

Planning for and Managing Infectious Disease Emergencies   Ruth M. Carrico, Ph.D., R.N., C.I.C; and Terri Rebmann, Ph.D., R.N., C.I.C.

49

Planning for an Influx of Infectious Patients

49

Exploring IC.01.06.01

50

Addressing the Cornerstones of Preparedness

51

Ensuring that the Plant is Ready

55

Examining Other Standards that Relate to Infectious Disease Emergencies

66

Applying Knowledge

66

Summary

66

Further Resources

69

Chapter 6

Interventions and Strategies to Reduce Infection Risk   Loretta L. Fauerbach, M.S., C.I.C.

69

Exploring IC.02.01.01

69

Summary

78

Further Resources

78

References

82

Chapter 7

Internal and External Communication Strategies and Mandatory Reporting Requirements   Shannon Oriola, R.N., C.I.C., C.O.H.N.; and Susan M. Slavish, B.S.N., M.P.H., C.I. C.

85

Reporting and Communicating About Infections

85

Exploring IC.02.01.01

86

Summary

94

References

94

Chapter 8

The Environment of Care and Infection Prevention and Control   Kathleen Meehan Arias, M.S., C.I.C; and Barbara Moore Soule, R.N., M.P.A., C.I.C.

95

The Impact of die Environment on Infection Prevention and Control Efforts

95

Exploring the “Infection Prevention and Control” and “Environment of Care” Standards

96

Summary

103

Further Resources

104

References

105

Chapter 9

Occupational Health Issues   Tammy S. Lundstrom, M.D., J.D.; and Susan Sebazco, R.N., B.S., C.I.C.

107

Exploring IC.02.03.01

107

Exploring IC.02.04.01

110

Summary

114

Further Resources

114

References

115

Chapter 10

Evaluating the Effectiveness of an Infection Prevention and Control Program   Candace Friedman, M.P.H., C.I.C; and Susan M. Slavish, B.S.N., M.P.H., C.I.C.

117

Evaluating Program Effectiveness

117

Exploring IC.03.01.01

118

Cost Evaluation

121

Taking a Multidisciplinary Approach co Evaluation

121

Summary

121

Further Resources

124

References

124

Chapter 11

Patient Safety and Performance Improvement   Kathleen Meehan Arias, M.S., C.I.C.

125

The Joint Commissions Infection Prevention National Patient Safety Goal

125

Exploring National Patient Safety Goal 7

126

Managing Sentinel Events Related to Health Care-Associated Infections

133

Summary

134

Further Resources

134

References

137

Chapter 12

The Joint Commission Accreditation Process   Louise Kuhny, R.N., M.P.H., M.B.A., C.I.C; and Barbara Moore Soule, R.N., M.P.A., C.I.C.

139

The Periodic Performance Review

139

The Priority Focus Process

139

The Unannounced Survey

140

Tracer Methodology

140

Summary

145

Further Resources

145

Index

147