APIC Creates Vision for the Future of Infection Preventionists' Competencies

By Kelly M. Pyrek

It's undeniable that the role and responsibilities of today's infection preventionist (IP) bear little resemblance to the infection control practitioner of the past. While the core tenets of infection prevention and control carry over as the foundation of the profession, the expectations for the position itself have evolved such that a new framework is needed to help professionals respond to these demands. With many months of tireless work behind it, the Association for Professionals in Infection Control and Epidemiology (APIC) is unveiling not only an updated strategic plan that articulates the association's vision for the future through 2020, but a set of professional competencies that will help IPs chart a corresponding course for their professional development.

 
APIC says that because the healthcare system has reached a critical juncture between patient safety, infection prevention and quality of care, these changes represent an unprecedented opportunity for IPs to accelerate progress toward the elimination of healthcare-associated infections (HAIs). As the strategic plan notes, "APIC leaders believe this is the right time to commit to an uncompromising vision and organize the associations mission and goals around a plan to advance toward healthcare without infection. We propose to advance our mission to create a safer world through prevention of infection and embrace this bold direction through patient safety, implementation science, competencies and certification, advocacy and data standardization."

"It is the most exciting time in my 30-year professional career in infection prevention because now we are getting the attention, the respect and the visibility within our organizations to help make a huge impact on patient safety," says Michelle Farber, 2012 APIC president. "So our expertise and skills are being recognized and used. I think that the hospitals that are the most successful have developed the kinds of goals that we have outlined in our strategic plan. We want to give our membership the support they need by elevating the position so that they are seen as leaders within their own organizations or state regulatory programs or collaboratives in which they participate. We are at a real crossroads in terms of how we need to be perceived as the leaders in driving prevention efforts -- we are becoming more visible, and we are being recognized as a leader of these initiatives instead of just being a participant."

With the help of a consulting firm, APIC has identified the factors that are driving change and shaping the future of infection prevention; these are.
- The future of healthcare focused on prevention and cost control
- The integration of evidence and outcomes-based research
- Anticipating and influencing regulatory change
- Empowered consumers demand for transparency, safety and accountability
- An automated future for data collection and risk assessment
- A global interconnected world encourages collaboration
These factors helped shape the strategic goals that APIC has set to achieve over the next eight years. Let's take a closer look at the five goals.

1. Patient safety goal
Demonstrate and support effective infection prevention and control as a key component of patient safety.
The objectives and initiatives are:
- Collaborate and align with key infection prevention and public health organizations, agencies and, consumer groups, including international engagement, to demonstrate and promote effective infection prevention programs across the care continuum.
- Define key processes of care that are shown to prevent infection.
- Develop framework to optimize partnership between providers and IPs as part of infection prevention programs.
- Create tools that integrate elements of the science of safety into infection prevention programs.
- Identify and assess measures that demonstrate the impact of infection prevention as part of patient safety.
 Indicators:
  Collaboration with organizations, agencies, and consumer groups at increased level
  Adoption of key processes of care by facilities
  Development and dissemination of evidence-based checklists and bundles of care in collaboration with physicians, other clinicians, and researchers
  Adoption of framework by other professional organizations
  Use of tools and resources by members
  Recognition of IPs as patient safety leaders within their organization and by regulatory bodies

2. Implementation science goal
Promote and facilitate the development and implementation of scientific research to prevent infection.
Objectives and initiatives:
1. Define implementation science (IS) and demonstrate the value of implementing the science of prevention to members, partners, and stakeholders.
2. Identify gaps in the research agenda and address the gaps.
3. Collaborate with related disciplines and organizations in promoting implementation science research.
 Indicators:
  Submission of well-designed scientific abstracts and papers in IS category at increased level
  Presentations at the APIC annual conference and other meetings that demonstrate use of IS by members
  Publication of white paper on gaps in research agenda
  Funding for IS research at increased level
  Submission of papers to peer-reviewed journals at increased level

3. IP competencies and certification goal
Define, develop, strengthen, and sustain competencies of the IP across the career span and support board certification in infection prevention and control (CIC) to obtain widespread adoption.
Objectives and initiatives:
1. Develop and refine APIC IP competency model and program for the career span.
2. Develop white paper and associated resources to support optimal use of the competency model for IPs and other leaders at the point of patient care.
3. Promote the value of CIC certification to key stakeholders, regulators, consumers and accreditors.
4. Explore options for supporting and recognizing IPs who have achieved an advanced/expert level of knowledge and skills.
Indicators
Publication and dissemination of IP competency model to members and partner organizations
Certification of 50 percent of eligible APIC members as CIC
Contribution of CIC on patient safety and infection prevention identified through sponsored research study

4. Advocacy goal
Influence and facilitate legislative, accreditation, and regulatory agenda for infection prevention with consumers, policy makers, healthcare leaders, and personnel across the care continuum.
Objectives and initiatives
1. Advance the development and adoption of scientifically valid, actionable, infection prevention measures and the necessary technology support that promotes appropriate data collection.
2. Support and advocate for resources that promote effective infection prevention and control efforts, programs, and initiatives.
3. Promote active IP participation and collaboration with organizational leadership of providers, consumer advocacy groups, and payers to enhance infection prevention and control on all levels and points of care.
Indicators
Awareness and understanding of HAI reporting measures and their role in prevention
Expansion of infrastructure for infection prevention and control programs
Communication and interaction with executive leadership at increased level

5. Data standardization goal
Promote and advocate for standardized, quality and comparable HAI data.
Objectives and initiatives
1. Support and participate in the strategic planning for advancing the description, collection, and reporting of HAI data.
2. Collaborate with government and private sector partners in initiatives supporting standardized and validated data for state and national reporting.
3. Advocate for expansion and interoperability of the electronic medical record (EMR) and standardized extractible infection data elements for state and national reporting.
Indicators
Engagement of IPs in development and use of HAI data for reporting with greater frequency
Use of HAI data validation processes by key stakeholders at increased level
Adoption of surveillance technology to support infection prevention and control programs and integration of IP data functions into emerging EMR systems at increased level

Infection Preventionists' Competencies
APIC says that the challenges posed by healthcare reform will require the infection preventionist to become a collaborative leader who can engage people and groups to work toward common goals that eclipse their traditional roles, disciplines and past experiences. This leadership is fundamental within an IP's core competencies on some level, but the challenge has been to define these competencies within the framework of the healthcare industry's paradigm shift. A standard, widely accepted, comprehensive definition of professional competency remains an elusive goal, according to Murphy, et al. (2012) -- until now. As Murphy, et al. (2012) report, APIC has developed a conceptual model of IP competency that is applicable in all practice settings and is designed to be used in combination with organizational training and evaluation tools already in place.

There are four domains that represent the areas that APIC has identified for future-oriented competency development: leadership, infection prevention and control, technology, and performance improvement/implementation science.

1. Leadership
Murphy, et al. (2012) explain that IPs leadership is based on influence rather than authority, and this influence is a consequence of five skills: collaboration, followership, program management, critical thinking skills and communication.
- Collaboration encompasses effective team- and consensus-building, and  Murphy, et al. (2012)  state that, "Managing competing agendas and priorities, while encouraging integration of prevention activities into the work of every department, takes a skilled negotiator. ... Influence and persuasion are especially important aspects of the IPs role in driving change through partnerships."
 - Followership encompasses the ability to follow a leader while demonstrating passionate commitment to the mission and active engagement. Murphy, et al. (2012)  state that, "IPs serve a supportive (follower) role when interdisciplinary teams are formed to prevent infections. This followership role allows the IP to provide expertise and exert influence in the absence of direct or traditional authority."
- Program management encompasses sensitivity to the organizations culture and emotional intelligence (EI), as well as to the many competing priorities that can impact desired clinical and operational outcomes, including economic trends. Murphy, et al. (2012)  state that,  "Alignment of the infection prevention programs goals with the organizational strategic priorities and annual operating plan is an important responsibility for every IP. Whether in a formal or informal managerial role, the IP must oversee daily prevention activities and the budget and allocate personnel and other resources while constantly balancing workload with patient-focused priorities."
- Critical thinking skills encompass a method of understanding the problems or questions at hand, as well as challenging assumptions and considering alternative perspectives. Murphy, et al. (2012)  state that, "In the context of IPC, this domain is about being proficient at understanding, utilizing and synthesizing scientific evidence, including methods for translating evidence into practice. This is an intellectual competency that focuses on goals, outcomes, and organization-wide impact of prevention initiatives. Judgment, reflection, complex reasoning, and analysis along with professional insight and wisdom are all necessary aspects of this skill set."
- Communication encompasses the verbal and written message that is a critical element of successful organizational leadership.  Murphy, et al. (2012) state that, "The ability to influence, serve as a role model, demonstrate accountability and integrity, and communicate the value of infection prevention to a diverse audience to achieve desired outcomes are all required for leadership competency. ...The art of influence and persuasion is also directly linked to communication competencies."

2. Infection prevention and control
Murphy, et al. (2012) emphasize that "IPC competencies are the foundation of the IPs development. IPs are subject matter experts in the epidemiology and natural history of infectious processes and pathogens, recognition of clusters and risk factors for infection, and methods for breaking the chain of infection."
Focus and expertise are required in the following areas:
- Epidemiology and surveillance
- Risk assessment
- Risk reduction and infection prevention
- Use and interpretation of diagnostic tests
- Antimicrobial stewardship
- Education
- Research

3. Technology
The heart of HAI surveillance is the systematic collection, analysis and dissemination of data to providers to drive improved performance. Murphy, et al. (2012) note that the "rapid escalation in the demand for HAI data highlights the critical need for IPs to use and advocate for standardized, validated and reproducible data." Managing these critical data will require mastery of electronic surveillance technology and health informatics, as well as the underlying computer and information technology-related skills. One current example of the need for this proficiency is reporting infection data to the NHSN, so familiarity with electronic surveillance systems in necessary. The move toward electronic medical records (EMR) is another key national trend that will require computer skills. As Murphy, et al. (2012) add, "IPs will need to be involved as early as possible in the evaluation and selection of an EMR vendor to assure that it provides meaningful use as defined by the needs of the HAI surveillance program."

4. Performance improvement/implementation science
As Murphy, et al. (2012) explain, "Performance improvement encompasses all of the systems, projects, and team activities an organization implements to achieve its goals. These goals include the prevention of HAIs for patients, visitors, and staff. Implementation science (IS) is 'the scientific study of methods to promote the systematic uptake of clinical research findings and other evidence-based practices into routine practice and hence to improve the quality (effectiveness, reliability, safety, appropriateness, equity, efficiency) of healthcare. It includes the study of influences on health care professional and organizational behavior.' Implementation science (IS) provides a conceptual basis for translating evidence into practice, addressing gaps between theory and practice, and serves as a useful clinical model to accomplish improvement in safety, quality, and effectiveness of patient care."
Murphy, et al. (2012) say that performance improvement (PI) methods and the principles of IS must be integrated into prevention program operations, and to accomplish performance/process improvement aimed at reduction of HAIs, the following elements are required:
- Identification of need for PI
- Assembly of PI team
- Tools and methods
- Implementation
- Measuring success

Hanchett (2012) explains that APIC will "promote and facilitate the development and implementation of scientific research to prevent infection" through the following objectives and initiatives: (1) define IS and demonstrate the value of implementing the science of prevention to members, partners, and stakeholders; (2) identify gaps in the research agenda and address the gaps; and (3) collaborate with related disciplines and organizations in promoting implementation science research. Hanchett (2012) adds that the inclusion of implementation science (IS) is critical to the current and future role development of the infection preventionist, and that the IP must acquire new competencies at integrating, as well as differentiating, PI and IS.

Certification is a key aspect of the strategic plan and the new competency model being promulgated by APIC. Murphy, et al. (2012) explain that the certification in infection prevention and control (CIC) credential "denotes mastery of fundamental knowledge required for competent performance of current infection prevention practice. Board certification in infection prevention is critical to professional development. It represents the bridge between the novice and the proficient professional. Although this transition is not readily quantified by years of practice, experience remains an important teacher and source of skill development as the IP progresses along the professional development path."

Murphy, et al. (2012) suggest that when IPs are conducting their annual goal-setting activities, they can perform a self-assessment of individual knowledge and skills and compare it to the aforementioned domains. They add, "The IP will quickly identify areas in which further education or skills development are needed and can integrate these domains into their own plans for professional development. The model can also serve to help inform and guide new IPs. It can be used as a general map for career planning and help direct those with less experience into areas where future knowledge and skills will be most needed and valued."

Q&A with APIC's Experts

ICT spoke with four experts from APIC to get their insights on the new strategic vision and core competencies for IPs. Our experts are:
- Katrina Crist, MBA, chief executive officer of APIC
- Michelle Farber, RN, CIC, 2012 APIC president and infection preventionist at Mercy Community Hospital
- Janet Haas, DNSc, RN, CIC, director of infection prevention and control at Westchester Medical Center
- Marilyn Hanchett, RN, MA, CPHQ, CIC,  senior director of research and clinical innovation for APIC

ICT: Was it challenging to come up with just four domains in the strategic plan?

Haas: There was a lot of give and take, thinking and rethinking, and it was a very collaborative process. We used consensus-building to see how elements should be grouped within the domains, and to ensure the elements we thought were important would fit.

Hanchett: We acknowledge that looking at future-oriented domains, we were talking about the near future -- we knew we didn't have a crystal ball, and we can't include every single element, so we had to be realistic and stay focused on what were the forward-thinking domains that would be essential in the next three to five years as a general timeline.

ICT: In terms of improving collaboration, how do you facilitate dialogue with peers and stakeholders?

Farber: It does take a few years to establish your expertise in your working relationships and to be respected as a leader, and it starts with collaboration. IPs should work closely with their patient safety and quality improvement managers and they will begin to involve you in some of their work. Sharing information and opportunities is a great way to get in front of your organization's leaders and demonstrate knowledge that will help them meet their strategic goals  -- which right now are tied into pay-for-performance. On other levels, it's about engagement with other members of the team, offering to help with shared challenges. Once you have an area in which you have success, more and more people will come to recognize that success and see you as a leader. And when you have that success, you will want to celebrate that, but be humble about it and point to being part of the collaborative team that was responsible for the success -- it takes a lot of humility, but it is the team that makes it happen.

Crist: I agree that humility is a great part of leadership. What we are trying to do is position IPs as organizational leaders, and have them embrace being seen within the institution as being able to influence that team for the greater good. We encourage them to reframe conversations so that everything leads back to patient safety. Part of what we will be doing with our new strategic plan is promulgating a new model of competency for IPs, emphasizing the message of board certification as a core competency, and bridging that to future-oriented domains, one of which is leadership and program management. We want to help IPs learn how to start a dialogue with an executive, whether it be related to electronic medical health records, or electronic surveillance, or the impact infection prevention is making. We want them to feel comfortable with getting a CFO or CEO's attention by way of sending something through the mail with a little note in the margin indicating how this information can help them understand infection prevention's role.

Hanchett: We know the value of sitting at the table at the executive suite level and talking about the contributions of infection prevention but the past we have been limited as to what we can bring with us to build a business case.  The intrinsic value of this model is that it gives us the opportunity to standardize the discussion and create a foundation from which we start to create a more consistent value proposition for the hospital executive suite and medical staff. If their view of infection prevention is that old model in which we are seen simply as the hand hygiene nurse or the person who does the flu shots, it will be hard to come in and argue for more resources and staff. With the introduction of the competency model, we start to articulate a much stronger proposition as to the value of the role and how we have opportunities through the future-oriented domains where collaboration is going to be essential. I think the one thing most facilities have learned is that infection prevention is not just the sole outcome of one person or one department -- everyone must be committed. This new model can change the whole context of the discussion. It opens the door to new types of collaborative opportunities if we choose to use it that way.

Haas: I agree. Trying to prove your value as an individual or as a department head in the face of everyone trying to do the same thing is difficult. Everyone has a case to make, but when you can articulate it from a higher level -- showing the standard for the profession and demonstrating that the institution could fall behind others who have adopted the standard -- you will be more successful. Most infection prevention departments are small relative to other departments in the hospital so it's harder to make that case for resources unless you come up with something definitive that sets a standard. The new competency model can be helpful in opening administrators' eyes to the scope of IPs work. IPs must be able to state what it is they do compellingly and convincingly. I think they will appreciate having a model they didn't have to create individually to help make the case.
 

ICT: The profession is very different today than it once was and IPs may feel overwhelmed. How best can they keep up with change and develop the skill sets needed to meet these expectations and challenges?

Farber: We have a new professional development council that has been formed as a way to help elevate IPs' competencies, a new model and framework to illustrate what their career would look like. We do have an aging membership, with many veterans having to change how they do things. We must also be able to recruit new innovators to the profession, and illustrate what it looks like to be a leader, and not just be perceived as the facility's hand hygiene cop. Rather, we want IPs to be able to demonstrate how their competencies will help make that vital connection with administration and impact patient safety and infection prevention. We are change agents, influencers and collaborators.

Crist: We may not have done as good a job as we could have to articulate the value of certification and core competencies in general. We know there are IPs in the field for many years who are not certified, but we believe strongly that it will elevate the profession overall to have the majority of IPs certified as well as working toward a higher level of competency. We are bringing that message to the IPs as well as to external stakeholders. For example, a recent study demonstrated that better outcomes are linked to certification, and there is a greater mandate for it --states are starting to require it, and we see job postings that require certification, so these things will help remove the barriers to those who have been in the profession for some time who might not want to move as quickly into this new direction as we would like them to.

Haas: I direct a department so I get to see this everyday. Typically the infection preventionist was a nurse or a microbiology tech that joins the IP profession; therefore why would they have command over tasks such as doing statistics or data collection? What new IPs have to learn is very broad. Some skill set instruction has been developed over time but it has not been a comprehensive, multi-modal approach. As part of that skill set we need to be conversant in performance improvement and know how to support change in an organization. The more the spotlight has been on infection prevention and control, the more IPs recognize their limitations -- in the past, you were just assembling and correcting the data, doing isolation and hand hygiene instruction or monitoring. The world has changed and the role of the infection preventionist has changed along with it. It's a wonderful thing, but we need to really support folks as they cope with change, and APIC is in the perfect position to provide that help. I think traditionally we have done a good job with infection prevention and control competencies, although people say they may be shaky on some of the statistics. They need help being the go-to person in their organization. It's not enough to just know about issues; you have to be the one to explain it to your colleagues and organizational leadership.  If you are simply doing data collection and reporting, you are at a different level than if you are in charge of making some improvement in the organization. People must be conversant with these new requirements, but how will they know if they are new to the position and they need to learn it all, or if they have been doing it in a particular way, focusing on the clinical piece of it for many years? The goal of the competency model and the new professional development council is to help IPs to fulfill the role as it now is and how we anticipate it will be in the next few years. The role has changed whether we move with it or don't move with it and as a nurse, I personally want to see myself and my colleagues in a position where we can be experts and leaders in patient safety.

Hanchett: Members speak often and poignantly about feeling they are in a reactive position, influenced by regulations and accreditation standards, Medicare and all these things that come flying at them and they are constantly having to react. Part of what we are doing with putting forth the strategic plan and the competency model, is moving them away from a reactive position and giving them tools to be proactive so when there is a major change in Medicare or there is a new HICPAC guideline, members are better positioned perhaps than in recent years to respond from a position of knowledge and strength and evolving skill sets instead of feeling overwhelmed. We see the road to 2020 as creating a new platform upon which we hope to evolve and get out of the past.  

ICT: What are those barriers to certification as perceived by IPs?

Farber: Certification is not necessarily recognized by the healthcare organization as much as it is with the nursing profession, and that needs to change. One of the strategies we have adopted is to demonstrate the value of infection prevention certification.  We must consider what a healthcare administrator or a member of the executive suite would want to hear about the value of certification. We also must demonstrate the value of certification to IPs as a way to demonstrate competency. After all, certification is the only way competency is formally recognized in the U.S., and more people are starting to consider  the value of having one's knowledge tested periodically as a way to ensure they are getting the best care delivery for their own safety. At the national APIC meeting in June we will have a panel that will provide perspective on what it means to have staff certified in infection control, with professionals at several levels explaining what certification has done for their careers and what motivated them to get certified. Katrina will moderate and explain what APIC is doing to support certification, and the CBIC will discuss its vision to elevate the value of certification. We will stand unified to say we believe in certification and want our members to get certified to demonstrate their professional development and be seen as leaders and be recognized as experts.

Crist: It is helpful to position certification to the executive suite as making the business case for infection prevention;  emphasize that the return is high that it relates to patient safety, and that it can even be a marketing tool for their facilities. We are launching a new scholarship because we are hearing from APIC members about financial barriers associated with certification. In order to help members remove some of these financial barriers,  our strategic partners have created an unrestricted fund that members will hear about in June. As it relates to the certification test itself, everyone is afraid of taking tests.  But when you look at the high level of credibility of the credential, it's not meant to be easy. There  may be a high failure rate to the initial examination, but the process is about increasing the competency and  the value as a demonstration of current knowledge in a very specialized area and we will help carry that message to the administrative and executive level.

ICT: A recent online poll of ours showed that 58.5 percent considered their professional competencies to be strong; what can IPs do to boost their confidence?

Farber: Ours is such a rapidly evolving science and keeping up with everything can feel overwhelming. However, there is so much information available these days, making it easier to access the current science that can advise on how to handle a specific infection prevention problem. Or e-mail members of your professional network or APIC chapter to solicit advice. I do wake up at night thinking about how I am going to handle a challenge, but that has been part of my career since I started -- infection prevention has never been stagnant and your day is constantly interrupted with new challenges. It's been like that for decades and we never feel caught up. But if you can learn even one new thing every day it adds to your overall knowledge base and skill set, and gradually builds your competencies. Stay abreast of issues, and keep current with APIC e-news and AJIC articles. It's valuable to build partnerships and networks to gain and share knowledge.

ICT: When a breach in infection control occurs, do you ascribe it to a knowledge gap or an implementation gap?

Farber: Our new professional development council will be able to provide members with what is needed to keep up their skills and address knowledge gaps.  The healthcare industry continues to develop tools such as bundles of care, which have been very successful in identifying key interventions that are important for ensuring good outcomes. APIC's elimination guides and the APIC text are examples of the many tools and resources that can help healthcare workers uphold patient safety. 

Crist: From the standpoint of knowledge and skills, it seems a majority of IPs do have the knowledge they need but we would like them to be credentialed and have the transparency that comes with it.  Over the next few years we are looking to help infection preventionists build upon their skill sets through leadership because what we are talking about is influencing change -- so much on the prevention and on the research side has advanced over the last five to 10 years. The challenge is implementing those changes, and that's where IPs truly can excel. We are helping them shift their skill sets to be more of an influencer throughout the organization as it relates to behavioral and cultural change.  

ICT: Let's talk about the importance of implementation science in infection prevention.

Farber: When advocating for implementation science, it comes down to the 80/20 principle -- 20 percent of our work is sharing the science around infection prevention, and 80 percent is working with the team, getting the engagement and letting healthcare workers  see what they need to do to reliably perform safe patient care and see the results of that work.  We are also looking at existing gaps in our research agenda and Katrina is working on improving our outreach for this research, how to implement it and how to make a change in outcomes.

Crist: We want to emphasize to IPs that their role speaks to interpretation of the science, because frankly, research is fairly meaningless unless it is implemented. You can have all the studies and concepts in the world but if no one puts them into practice, it doesn't make much of an impact.

ICT: What gets you excited about APIC's strategic vision?

Farber: I want to have the IPs resonate with the fact we are here to support them in being successful and this is the one time again in my career I have seen the greatest opportunity to have our profession be elevated, recognized and supported -- our APIC primary objective is to meet our members' needs and help them be successful.

Crist: It is an exciting time and the passion and the commitment of the members and those who work as IPs has been very inspiring to me.  I think the plan is well grounded and we will be able to achieve what we have put forward.  The advocacy side is very important for any professional association, and what we can put forth with the collective voice of 14,000 members is amazing. I think you will see IPs come into their own.