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Navigating through Frontline

Competencies, Training and Audits

Carol Vance MSN, RN, CIC

Multi-site Director, Infection Prevention

Advocate Children’s Hospital

Objectives

• Discuss the relationship between training, competency and audits.

• Provide concrete and practical solutions to training and competency challenges.

• Identify the key stake holders that are important for training and competency success.

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Infection Preventionist Daily Work

Infection Control Assessment and Response (ICAR) Program

• The Infection Control Assessment and Response Tools were developed by CDC

• Used by healthcare facilities to conduct internal quality improvement audits

• Assessment tools• Acute care (including short stay acute and long-

term acute care hospitals)• Outpatient• Long-term care• Hemodialysis

Healthcare Personnel Infection Prevention Competency

Healthcare Personnel Infection Prevention Competency Based Training

Competency Assessment

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APIC Competency Domains

Domain 2: Infection Prevention and Control

Domain 4: Performance Improvement and Implementation Science

Healthcare Personnel Infection Prevention Competency

• The proven ability to apply essential knowledge, skills, and abilities to prevent the transmission of pathogens during the provision of care

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Domains with Gaps in Training and Competency

• Hand Hygiene• Central Line Associated Blood Stream Infection

Prevention (CLABSI)• Catheter Associated Urinary Tract Infection (CAUTI)• Low Level Disinfection• Personal Protective Equipment• Injection Safety• Ventilator Associated Events (VAE)

Healthcare Personnel Infection Prevention Competency-Based Training

The provision of job-specific education, training, and assessment to ensure that healthcare

personnel possess IP competency

Competency-based Training

• Infection Control Risk Assessment

• Educational Needs Assessment

• Job-specific employee roles

• Department-specific needs

https://www.freepik.com/free-vector/medical-team-design_1023371.htm#term=nurse&page=1&position=45

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Competency-based Training

• Direct observation/return demonstration

• Methods to assess competency

• Documentationhttps://www.freepik.com/free-vector/statistical-data-abstract-on-paper-and-tablet_1311213.htm#term=documentation&page=2&position=0

Assessing Educational Needs

• Methods that can be used to determine educational needs of the learner population include the following:

• Learner self-assessment• Focus group discussion• Test development• Personal interviews• Job analysis and performance reviews• Observational studies

https://www.freepik.com/free-vector/to-do-list-concept_1577756.htm#term=tests&page=1&position=32

Learning Retention

APIC Text Ch 2

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Training Strategies

• Case studies

• Simulation • Quizzes • Games

• Role-playinghttps://www.freepik.com/free-vector/man-and-woman-presenting-their-project-business_1311616.htm#term=training page=1&position=16

Competency Assessment

• The verification of IP competency through the use of knowledge-based testing and direct observation

• Audit• Direct observation or monitoring of healthcare personnel

adherence to job-specific IP measures

• Feedback• Communication of audit results to the end user

Audit and Feedback Process

• Determination of number and frequency of audits

• Engage staff in auditing and performance improvement processes.

• Communication of audit results• Informal random audits

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Key stake holders

• Senior Leadership

• Nursing• Environmental Services• Education Department

• Facilities• Medical Staff

https://www.freepik.com/free-vector/illustrated-medical-teamwork_831095.htm#term=medical&page=8&position=31

ChallengesIdentified

During ICAR Visits

Hand Hygiene & Personal Protective

Equipment (PPE)

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Hand Hygiene

• Opportunity• Return demonstrations are not utilized to

demonstrate competency

• Recommendations• Risk assessment to review hand hygiene

compliance data to determine if instituting a return demonstration into position and/or department-specific annual competency/performance assessment checklists

Personal Protective Equipment (PPE)

• Opportunity• PPE training does not include information on or a

return demonstration of donning and doffing

• Recommendations• Training at hire and annually • Return demonstration

• validated by the preceptor in the clinical space

• Evaluate the benefit and feasibility of adding to annual skills day training and/or competency assessment

• CDC resources

PPE Utilization

• Opportunity• PPE selection and proper use are not monitored

• Recommendations• Hand hygiene compliance observers to collect PPE

compliance data• Utilize an app suggested for hand hygiene

observations that can also be used to collect PPE compliance data

• The University of Iowa. iScrub Lite. Available at: https://itunes.apple.com/us/app/iscrub-lite/id329764570?mt=8 Accessed August 11, 2017

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Prevention of CAUTI

Training

• Opportunity• Staff do not receive annual training on indwelling urinary

catheter insertion

• Recommendations• Minimum - include didactic information on insertion of

indwelling urinary catheters on an annual basis • The Joint Commission (TJC) National Patient Safety

Goal (NPSG) 07.06.01 • Annual insertion return demonstration for the

units/locations with the highest CDC National Healthcare Safety Network (NHSN) cumulative attributable difference (CAD) produced by the targeted assessment for prevention (TAP) report

Computer Based Training

• Opportunity• Annual training for insertion and maintenance of an

indwelling urinary catheter is computer based and does not include a return demonstration

• Recommendations• Utilize CAUTI outcome and process measures to

assess the need for return demonstration for insertion and maintenance on an annual basis

• Results may indicate that return demonstration would only be beneficial on certain units

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Insertion and Maintenance Audits• Opportunity

• Indwelling urinary catheter insertion and maintenance audits are not conducted and; therefore, feedback on performance is not provided to the frontline staff

• Recommendations• TJC NPSG.07.06.01 states that CAUTI process and

outcome measures should be collected • Infection prevention and control risk assessment

and/or the CDC NHSN CAD • Implementing a two-person • Feedback of the audit data and lessons learned

Prevention of CLABSI

Licensed Independent Practitioners (LIP)

• Opportunity• Licensed independent practitioners (LIP) do not

participate in an initial or annual standardized training and competency assessment program for insertion of central lines

• Recommendations• Standardizing central line insertion practices for LIPs• Central line insertion practices in the credentialing

process• Investigate the use of the simulation • The insertion checklist could be added to the LIPs

credentialing

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Audits and Maintenance

• Opportunity• Neither central line insertion nor maintenance audits are

conducted and; therefore, feedback on compliance with best practices cannot be provided

• Recommendations• Central line insertion checklist • TJC has examples of insertion checklists in their

CLABSI Toolkit • Explore use of the Electronic Medical Record for

documentation of the insertion checklist data and then leverage the electronic capture to produce reports on compliance

• Report compliance • Provide both metrics to frontline staff

Feed Back

• Opportunity• Insertion and maintenance audit data are collected,

but not routinely fed back to the frontline clinicians

• Recommendations• Utilize computer documentation to create reports to

provide the information to frontline staff• Feedback will inform staff of the gaps in practice

and progress of improvement efforts

Maintenance

• Opportunity• The facility does not have an annual competency

based training program for maintenance of central lines

• Recommendations• Consider the use of the NHSN CLABSI CAD to

target units for annual maintenance competency including return demonstration, particularly if surveillance data suggests CLABSIs are related to maintenance

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Prevention of Ventilator

Associated Events (VAE)

Training

• Opportunity• Formalized competency based training for

prevention of VAEs is not provided at hire or annually

• Recommendations• Collaborate with nursing and respiratory therapy to

develop a competency based training program for the prevention of VAEs

Injection Safety

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Training

• Opportunity• Staff do not receive training on safe injection

practices at hire or on an annual basis

• Recommendations• Patient safety component of Standard Precautions• CDC One and Only Campaign to initial and annual

training

Audits

• Opportunity• Safe injection practice audits are not completed

• Recommendations• Include injection safety tracers into environment of

care and/or regulatory rounds • Formal feedback to clinical staff and modify

education and competency to address identified gaps

• Random documented audits of scrub the hub protocols

• Engage unit champions to complete the audits • Provide feedback of the audits to frontline staff

Audit and Feed Back

• Opportunity• No formalized audit or feedback process has been

established for monitoring point of care testing or safe injection practices

• Recommendations• CDC-defined Training Programs and Audit

Processes section • Routinely share audit results with frontline staff. • Utilize the contracted pharmacy to assist with safe

injection practices audits

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Prevention of Clostridium difficle Infection (CDI)

• Opportunity• Recommended practices for prevention of CDI are

not audited

• Recommendations• Review the CDI CAD to focus improvement efforts• Discuss the use of best practices audits with the

CDI prevention team• Focusing audits on units with the highest CAD

• Identify gaps and allow for focused improvement initiatives

• Communicate feed back of audit results

Environmental Cleaning

• Opportunity• Surgery staff is responsible for cleaning and

disinfection of OR suites. Surgery staff have not received training for environmental cleaning and disinfection

• Recommendations• The EVS manager should provide education and

training to the surgery staff on how to use products and how to effectively clean and disinfect the OR space

• Document the training

Antibiotic Stewardship

• Opportunity• All clinical staff have not received antimicrobial

stewardship education

• Recommendations• Engage frontline staff • Educate them on the importance of antibiotic

stewardship and speaking up for judicious use of antibiotics

• Review the contract and roles/responsibilities of the pharmacist

• Research other possible resources to support stewardship

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StrengthsIdentified

During ICAR Visits

Training and Competency

• Each department performs an annual one-page risk assessment that includes but is not limited to

• High risk• High volume• Low volume • Pertinent data• Staff input to identify top three of ten competencies

per job code per year to target for education and training

Hand Hygiene

• The IP meets with all new employees and provides hand hygiene education during orientation

• Hand hygiene competency is assessed by return demonstration

• Glo Germ and ultraviolet light training tool • Annual training is provided by use of a

computer-based learning module

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Personal Protective Equipment (PPE)

• PPE use and compliance is being monitored by the secret shoppers who complete HH audits

• Infection preventionist has coined a saying, “no flourishing”

• The IP feels this has helped staff understand the concept of spreading germs or routes of transmission

• Prevention of CAUTI• Training and education for urinary catheter insertion

is done upon hire. Personnel are observed when they insert their first catheter

• Prevention of CLABSI• The central line insertion checklist is required to be

completed for all line insertions even if inserted by a CRNA or surgeon

• The IP receives all central line insertion checklists for review

• Any omissions or deviations are dealt with on an individual basis

Injection Safety

• The facility’s tracer team performs injection safety tracers in all clinical areas twice per year

• Tracer data are entered into a database for follow-up by appropriate managers

• Managers’ follow-up actions are tracked and trended

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Environmental Cleaning

• New EVS staff receive one-to-one training and shadow with a designated mentor until competency is demonstrated

• The IP uses Glo Germ powder and ultraviolet light technology to monitor surface cleaning

• The hospital has a well-developed orientation and training program for staff working in the environmental services (EVS) department

• New hires are paired with a trainer for one to two weeks

• The EVS manager validates skills

Ambulatory & Ambulatory Surgery Centers

• Training and Competency• All sterile reprocessing technicians are certified

through The International Association of Healthcare Central Service Material Management (IAHCSMM)

• Gastrointestinal (GI) endoscopy registered nurses (RNs) are cross-trained and rotate through pre/post, procedure and reprocessing areas. All training includes return demonstration

• Hand Hygiene• All HCP must demonstrate hand washing

competency during orientation

Questions?

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Resources

• Centers for Disease Control and Prevention. Infection Control Assessment Tool. https://www.cdc.gov/hai/prevent/infection-control-assessment-tools.html. Accessed April 18, 2017 Centers for Disease Control and Prevention. Infection Control Assessment Tool. https://www.cdc.gov/hai/prevent/infection-control-assessment-tools.html. Accessed April 18, 2017.

• Centers for Disease Control and Prevention. Sequence for Donning and Doffing Personal Protective Equipment. Available at: https://www.cdc.gov/HAI/pdfs/ppe/ppeposter148.pdf Accessed July 26, 2017.

• The University of Iowa. iScrub Lite. Available at: https://itunes.apple.com/us/app/iscrub-lite/id329764570?mt=8 Accessed August 11, 2017.

• The Joint Commission. National Patient Safety Goals, Hospital Accreditation Program. Goal 7, NPSG.07.06.01 EP1. January 2017. Available at: https://www.jointcommission.org/hap_2017_npsgs/ Accessed July 26, 2017.

• Centers for Disease Control and Prevention. The Targeted Assessment for Prevention (TAP) Strategy. Available at: https://www.cdc.gov/hai/prevent/tap.html Accessed July 20, 2017.

• The Joint Commission. National Patient Safety Goals, Hospital Accreditation Program. Goal 7, NPSG.07.06.01 EP1. January 2017. Available at: https://www.jointcommission.org/hap_2017_npsgs/ Accessed July 26, 2017.

• Centers for Disease Control and Prevention. The Targeted Assessment for Prevention (TAP) Strategy. Available at: https://www.cdc.gov/hai/prevent/tap.html Accessed July 20, 2017.

• The Joint Commission. CLABSI Toolkit- Chapter 3. Available at: https://www.jointcommission.org/topics/clabsi_toolkit__chapter_3.aspx Accessed July 27, 2017.

• Agency for Healthcare Research and Quality. Tools for Reducing Central Line-Associated Blood Stream Infections. Available at: https://www.ahrq.gov/professionals/education/curriculum-tools/clabsitools/index.html Accessed July 27, 2017.

• Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings Available at: https://www.cdc.gov/infectioncontrol/guidelines/isolation/ Accessed July 28, 2017.

• Centers for Disease Control and Prevention. One & Only Campaign. Available at: http://www.oneandonlycampaign.org/ Accessed July 20, 2017

• APIC professional and practice standards Tania N. Bubb, Corrianne Billings, Dorine Berriel-Cass, William Bridges, Lisa Caffery, Jennifer Cox, Moraima Rodriguez, Jessica Swanson, and others, American Journal of Infection Control, Vol. 44, Issue 7, p745–749 Published online: April 11, 2016

• APIC Text

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