1. Leadership and Management

Infection Control in Healthcare Personnel

What to know

• Guideline: Infection Control in Healthcare Personnel
• Segment: Part I Infrastructure and Routine Practices
• Summary: Recommendations and resources for the leadership and management elements of infection prevention and control among healthcare personnel.

Additional Recommendations

See section 2. Communication and Collaboration for additional related recommendations.

For healthcare organization leaders and administrators

Number

Recommendation

1.a.

Invest in an organizational culture that prioritizes safety and occupational infection prevention and control.

1.b.

Regularly review organizational information about occupational infectious risks, exposures, and illnesses with occupational health services.

1.c.

Dedicate one or more persons with appropriate authority and training to lead occupational infection prevention and control services.

1.d.

Provide sufficient resources (e.g., expertise, funding, staff, supplies, information technology) to implement elements of occupational infection prevention and control:

• Leadership and management,
• Communication and collaboration,
• Assessment and reduction of risks for infection among healthcare personnel populations,
• Medical evaluations,
• Occupational infection prevention and control education and training,
• Immunization programs,
• Management of potentially infectious exposures and illnesses, and
• Management of healthcare personnel health records.

1.e.

Oversee, and include occupational health services leaders in, performance measurement and continuous quality improvement activities for occupational infection prevention and control services.

For occupational health services leaders and staff

Number

Recommendation

1.f.

Promote an organizational culture with a consistent focus on safety and occupational infection prevention and control.

1.g.

Develop occupational infection prevention and control services that are tailored to the needs of healthcare personnel and the environment in which they work.

1.h.

Develop, review, and update when necessary, written policies and procedures that adhere to federal, state, and local requirements for elements of occupational infection prevention and control services:

• Leadership and management,
• Communication and collaboration,
• Assessment and reduction of risks for infection among healthcare personnel populations,
• Medical evaluations,
• Occupational infection prevention and control education and training,
• Immunization programs,
• Management of potentially infectious exposures and illnesses, and
• Management of healthcare personnel health records.

1.i.

Inform all healthcare personnel and relevant healthcare organization departments about occupational infection prevention and control policies and procedures.

1.j.

Collaborate with appropriate healthcare organization departments and individuals to:

1.j.1.

Achieve compliance with regulations related to occupational infection prevention and control.

1.j.2

Develop infectious disease emergency and outbreak management plans.

1.j.3

Develop and monitor performance measures for occupational infection prevention and control services that include the proportion of healthcare personnel with documented evidence of immunity and the proportion of healthcare personnel vaccinated, as appropriate, for each vaccine-preventable disease recommended for healthcare personnel by the Advisory Committee on Immunization Practices (ACIP).

1.j.4

Set and meet quality improvement goals for occupational infection prevention and control services and report performance measures and areas for improvement to management.

1.j.5.

Periodically assess the effectiveness of occupational infection prevention and control services.

Background

Leader(s) of OHS oversee the delivery and monitor the quality of occupational IPC services. Planning and decision-making can be shared with other parts of the organization, including human resources, facility IPC services, facilities management, and environmental services. HCO leadership support for OHS leaders is critical for facilitating intra-organizational collaboration and the effective provision of occupational IPC services.

OHS leaders improve the delivery and quality of occupational IPC services by:

• developing both routine and emergency response policies and procedures for occupational IPC services,
• providing accountability for occupational IPC service delivery and quality,
• engaging in continuous quality improvement activities that improve OHS, and
• fostering collaboration with other departments or programs that address IPC.

Ensuring the provision of high-quality occupational IPC services can have many benefits, including:

• improvement of HCP health, job satisfaction, and morale,
• support for a HCO safety culture,
• prevention of HCP infections and enhancing the health of patients and others (e.g., co-workers, family members) with whom HCP interact, and
• economic savings for the OHS and HCO.

The leadership and management of OHS vary widely depending on HCO structure, the location of services with respect to HCP served, facility types and sizes, clinical activities, and HCP characteristics. These variations can affect how, and where, services are provided to HCP. Several organizations provide profession-specific certifications in occupational medicine that include occupational IPC services. For instance, the American Board of Preventive Medicine offers Certification in Occupational Medicine, and the American Board for Occupational Health Nurses offers credentialing as a Certified Occupational Health Nurse and as a Certified Occupational Health Nurse-Specialist. Additional training for OHS leaders and staff focusing on occupational IPC can be developed by an individual HCO or OHS to address the specific needs of their work settings.

Abbreviations

• CMS = Centers for Medicare & Medicaid Services
• CoP = Conditions of Participation
• HCO = Healthcare Organization
• HCP = Healthcare Personnel
• IPC = Infection Prevention and Control
• OHS = Occupational Health Services
• OSHA = Occupational Safety and Health Administration
• PPE = Personal Protective Equipment

Compliance with requirements and standards

OHS leaders may be responsible for ensuring alignment with practice standards, such as clinical guidelines, as well as federal, state, and local requirements. Examples of federally mandated services include, but are not limited to, implementing all applicable requirements of the OSHA Bloodborne Pathogens standard, including annual updates of exposure control plans and providing exposure management services to employees, and implementing applicable Personal Protective Equipment standard requirements for PPE, including training and demonstration of competency.

In addition, OHS leaders can ensure alignment with HCO goals for accreditation and reimbursement. For example, The Joint Commission requires that facilities set goals for incremental influenza immunization for HCP

Performance measurement and quality improvement

Performance measures are objective metrics of various aspects of a service's performance, such as service delivery or outcomes. They can be used to inform OHS and HCO leadership when occupational IPC services are not meeting goals, support the identification of areas for improvement, and quantify progress on quality improvement initiatives by examining trends over time. Regulatory and accreditation groups, payers, and purchasers can require performance measurement or quality improvement activities for OHS, such as the CMS requirement to report HCP influenza immunization coverage as a CoP

Emergency planning and outbreak response

The transmission of emerging pathogens to HCP has been reported with increased frequency and highlights the importance of OHS participation in HCO planning for such events. Examples include HCP infections with pandemic influenza

Box 1. Examples of Performance Measures that Might Be Used to Assess the Effectiveness of Occupational Infection Prevention and Control Services

Occupational Infection Prevention and Control Services

Examples of Performance Measure(s)

Assessment and Reduction of Risks among HCP Populations

• Number of HCP who sustain potentially infectious exposure events
• Number of HCP infectious exposure events through specific mechanisms (e.g., bloodborne pathogen exposures from sharps injury and mucosal exposure, or inappropriate, malfunctioning, or non-use of PPE)
• Number of HCP who develop infections as a result of occupational exposures

Medical Evaluations

• Proportion of HCP who underwent preplacement evaluations
• Proportion of HCP who completed screening for latent TB infection, when recommended by CDC
• Proportion of HCP using N-95 respirators who received annual fit testing

Occupational IPC Education and Training Programs

• Proportion of HCP who completed initial and annual refresher occupational IPC education and training

Immunization Programs

• Proportion of HCP with documented evidence of immunity to each vaccine-preventable disease recommended for HCP by ACIP
• Rates of completed HCP vaccination, when indicated, for each vaccine recommended for HCP by ACIP

Management of Potentially Infectious Exposures and Illnesses

• Proportion of HCP who sustained infectious exposures and were offered post-exposure prophylaxis within recommended timeframes

Footnotes

• See section 3. Assessment and Reduction of Risks for Infection among Healthcare Personnel Populations for further information regarding how to approach assessments and interventions to improve performance measures that do not meet goals.
• Some examples in this box correspond with activities required by the Occupational Safety and Health Administration (OSHA).
• The NHSN Surveillance for Healthcare Personnel Vaccination page provides information on reporting HCP influenza immunization coverage to NHSN.

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