By Karin Lillis
While Joint Commission standards require hospitals to identify those responsible for infection prevention and control programs, its up to the organization to determine staffing and skill mix based on hospital goals.
The organization needs to figure out what it needs based on its goals and risk assessment, says Louise Kuhny, RN, MPH, MBA, CIC, clinical educator for accreditation and certification operations for the Joint Commission.
Large university medical centers nearly always have a masters-prepared person leading a team of infection preventionists all certified in their profession. By contrast, a rural 30-bed hospital could have an LPN in the role of infection preventionist.
A smaller facility, for example, might decide it wants to target zero for central line-associated infections, so it beefs up its infection prevention staff. Although theres low risk with that smaller facility, the hospital goes after that goal aggressively, Kuhny says.
Its crucial for hospitals to assess the competencies of the infection preventionistno matter who fills the role. We do expect that people in infection control have some sort of specific infection prevention training, Kuhny says. Although the Joint Commission doesnt specify an educational provider, most of the training is provided through Joint Commission Resources and organizations like the Association for Professionals in Infection Control and Epidemiology (APIC).
Joint Commission surveyors will also look for evidence of ongoing education among infection control staff, and that can be a variety of formats, Kuhny says. For example, members of APIC might be involved in their local chapters. Other resources include professional conferences, journals, weekly updates from the CDCs Morbidity and Mortality Weekly Report and information released by state health departments.
Joint Commission surveyors will review personnel files for infection preventionists, and theyre looking for specific training as well as ongoing education, Kuhny says.
Sometimes surveyors find that an infection preventionist doesnt have adequate initial training, or infection control staffing is inadequate for the particular organization. Kuhny says surveyors are not looking for a certain number of staff the Joint Commission doesnt have a required ratio. Rather, the focus is on symptoms of understaffing, like unmet infection prevention goals and lack of interventions.
She shares two scenarios that immediately make surveyors suspicious.
Infection control data is months behind. That can include surveillance data and public reporting as required by individual state law. Its a serious matter, Kuhny says.
Staff dont know who to call if they encounter an infection control problem. They might not know the infection control nurse, or the infection preventionist doesnt have time to round on all units, Kuhny says. Its very important to have an excellent working relationship particularly with the nursing staff so they know who to call and can trust you.
Karin Lillis is a freelance writer.