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The Compliance Team
Developing an Infection Control Program in the Clinic Setting
- Dianne Bourque, RN, CNOR, CASC

Centers for Medicare & Medicaid Services (CMS) has steadily increased focus on infection control issues in healthcare facilities and The Compliance Team has seen a large number of deficiencies in this area.

In clinics, the problem seems to occur most frequently when there are too few resources to provide meaningful initial training and competency assessment of the staff performing key infection control duties in the clinic. The governing body must adopt recommended infection control guidelines, designate a licensed healthcare professional to oversee the program, assign a staff member responsible for initial (and ongoing) training/competency validation, and develop a process to regularly monitor for updates and amend the clinic’s practices as needed.

Initially, the clinic should perform a risk assessment determining areas where policy, education and competency are essential to protect both patients and staff. Occupational Safety and Health Administration’s (OSHA) Bloodborne Pathogens standard prompts the development of a comprehensive program focused on protecting employees. Often, a clinic struggles when developing protocols for areas not covered by OSHA. These may include environmental cleaning, equipment disinfection, safe injection practices, aseptic technique and sterilizing reusable surgical instrumentation.

At a minimum, a clinic should print and review the Center for Disease Control and Prevention’s (CDC) “Guide to Infection Prevention for Outpatient Settings” (updated 2015) and “Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008.” If reusable surgical instruments are used, site-specific protocols must be developed even when the instruments are not sterilized in the clinic. For additional resources and training tools, specialty organizations such as Association of periOperative Registered Nurses (AORN), Association for the Advancement of Medical Instrumentation (AAMI), and Association for Professionals in Infection Control and Epidemiology (APIC) can be consulted. After consideration of recommended practices, the clinic should create written protocols noting the actual practices of the clinic, approve the drafts and then create policies to be used in training.

The CDC and the Safe Injection Practices Coalition have developed the “One & Only Campaign,” which offers free educational material and has a number of short videos online which are packed with information. The video “Safe Injection Practices - How to Do It Right” is an extremely effective teaching tool about the use of Multiple-Dose Medication Vials in patient care areas. There are many fun and efficient ways to incorporate education into your orientation and annual training programs, which must include all staff members, including providers.

Ideally, a licensed professional who has received formal infection control training should be assigned as the clinic’s infection control trainer. Should the areas of need exceed the experience/competency of the clinic’s staff members, it is time to consider bringing in help, often from the nearest hospital. Certified staff members are usually proud to be able to teach in their community. This need not be extensive or expensive. The initial training can usually be accomplished in a class held in the clinic.

Before the class, have the trainer come by the clinic to determine baseline practices, the tools and supplies currently used, what supplies need to be ordered, and how much time is required for training. Identify the staff member best suited to have future oversight and give that employee extra time with the trainer, encouraging them to perform spot checks together until compliance is achieved. By establishing competency and providing a written guideline to follow in the future, this train the trainer program can be highly effective.

A culture of safety must be established and led from the top down. Having conversations with providers and team members before a program rolls out can set the tone for the importance of the new activities. If the clinic’s comprehensive infection prevention program is carefully cultivated and developed to include monitoring tools (such as checklists, audits, and logs), spot checks by leadership, and on-going training of all staff members, they will be primed for success.

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