EC 53 - Achieving Survey-readiness Through Standardized Infection Prevention Rounding Tools

Background: National Infection Prevention (IP) environmental guidelines were developed to prevent healthcare associated infections from the environment. These standards have become extensive and can be difficult to interpret and implement. Our integrated health system began a yearlong project to develop a standardized, comprehensive IP rounding program to create robust data, a safer environment of care (EOC), and a constant state of survey-readiness.

Methods: IP’s focus on the EOC requires partnerships with hospital leadership and Accreditation. This team engaged Accreditation partners to collaborate on a standardized approach and leveraged their knowledge, data, and software platform, Joint Commission Resources (JCR). Our large, integrated 11 hospital health system had various rounding tools in place and all were evaluated. The team recognized the significance of high-risk areas and common accrediting survey findings and created specialized tools to address these. Finally, the team confirmed all survey items were evidence-based and mapped to Joint Commission (JC) standards.

Results: The survey evaluation resulted in nine standardized general and specialized rounding tools housed in the JCR platform. The previous non-standardized tools were retired, and new tools implemented. Prior to implementation, 26 infection preventionists were educated on EOC rounding and use of the tool. All survey items were mapped to JC standards, allowing users to connect their observations to relevant findings. Utilizing one standard platform allowed for one data repository for the program. The team grouped findings by frequency for local hospitals and the overall system. Custom reports were created for each hospital and department to communicate opportunities.

Conclusions: Workflow standardization is a priority in a large health system. The EOC impacts patients, IP programs, and accreditation status. A standardized EOC rounding program provides actionable data to hospital leadership, improves performance and aligns care practices across a system. Data is used to show improvement over time and results in fewer JC survey findings.