Pharmacy OneSource Blog

Clinical Corner: The First Step to Reducing Infection Risk: Evaluate Existing Infection Prevention Processes

Posted on 09/12/13

"If you want to know your past, look into your present conditions. 
If you want to know your future, look into your present actions."  - Chinese Proverb 


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: 

  1. Inventory current policies and procedures and review for content guided by evidence-based science. Are updates or new policies and procedures needed?
  2. Define current surveillance activities related to process and outcome metrics. Is the data generated from these activities used to enhance patient safety?
  3. 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)

infection prevention


Topics: Infection Prevention

About the Author

Keith H. St. John, MT(ASCP), MS, CIC has served as an Infection Preventionist for the past 30 years, including over 17 years of managing Infection Prevention and Control programs and personnel at major tertiary teaching institutions that include pediatric as well as adult hospital settings. Keith is a clinical microbiologist by training and is certified in Infection Control & Epidemiology (CIC). Keith’s rich professional experience includes: Past President of the Certification board of Infection Control & Epidemiology (CBIC); publications in medical and infection control journals; presentation at national and regional conferences; and former faculty associate at Temple Dental and Medical School. Mr. St. John is also a former member of APIC’s Governmental Affairs Committee, Education Committee, Practice Guidance Council and Research Foundation. He has served APIC as Chapter President & Board member, Editorial Board and reviewer for AJIC, APIC Text Revision Task Force (x2) and Pharmacy chapter co-author. Keith has been a volunteer member of the United States Pharmacopeia Convention Expert Compounding Committee since 2005, sharing his expertise on the revision of USP Chapter <797>, Pharmaceutical Compounding – Sterile Preparations. In addition to APIC, he is an active member of the Healthcare Infection Society (UK) and the Society for Health Epidemiology of America (SHEA). Keith received his Master’s of Science degree in Clinical Microbiology from Thomas Jefferson University in Philadelphia and his Bachelor of Science degree in Medical Technology from the University of Delaware.