It is no secret that healthcare-associated infections lead to significant morbidity and mortality. CMS has addressed HAI prevention in its Partnership for Patients initiative, creating 26 Hospital Engagement Networks (PFP-HEN) and setting a goal to reduce hospital-acquired conditions by 40% and readmissions by 20%. When you are faced with such a challenge, where do you begin?
Performing a programmatic gap analysis is a strategic method for evaluating your current infection prevention efforts. The Chinese Proverb quoted above rings true in this case; to address any apertures, you need to define where you have been (“know your past”) and ensure that your program is current with recommended evidence-based practices.
For instance, the Ascension Health system (part of PFP-HEN) administered a 96-question survey to infection preventionists at the 71 hospitals in their system to identify opportunities for improvement for CLABSI, CAUTI, VAP and SSI. This survey had 100% participation by an IP from each of their 71 hospitals. Once the data was analyzed, it clearly showed opportunities for improvement for each of these infection types based upon this gap analysis survey.
Developing a gap analysis should be tailored to your facility’s processes and workflow. Here are three considerations that may be helpful when creating a gap analysis:
- Inventory current policies and procedures and review for content guided by evidence-based science. Are updates or new policies and procedures needed?
- Define current surveillance activities related to process and outcome metrics. Is the data generated from these activities used to enhance patient safety?
- Assess compliance of clinical staff that perform invasive procedures with recommended best practices for infection reduction. Are checklists being used as reminders of best practices?
A gap analysis can be a valuable tool for your annual programmatic risk assessment and prioritization of HAI reduction efforts. I applaud Ascension Health’s system-wide approach, which allowed for the identification of common program gaps, and the ability to address them as a health system with the goal of improving patient safety. It is through efforts of this type that the goal set forth by the PFP-HEN can be achieved.
References: Fakih, MG, Heavens, M, Ratcliffe, CJ, Hendrich, A. First step to reducing infection risk as a system: Evaluation of infection prevention processes for 71 hospitals. American Journal of Infection Control xxx (2013): 1-5. (In Press)