QAPI 118 - Making Construction Compliance Visible: Developing a Joint Commission Resources Tracer for Infection Prevention Mitigation Measures During Construction

Background: Environmental disturbances which occur during construction or renovation projects can create an infection prevention and control (IPC) risk in healthcare settings. Through the Infection Control Risk Assessment (ICRA) process, Infection Preventionists (IPs) work to ensure mitigation measures are in place to reduce the of risk harm during construction or renovation. Construction and renovation projects at a four hospital and ambulatory clinic system are managed by one infection preventionist. A standardized construction site audit and feedback tool did not exist.

Methods: To standardize the observations and feedback, a Construction Site Infection Preventative Measures Observation tracer tool was created using the Joint Commission Resources (JCR) tracer software. The tracer focused on major mitigation categories including appropriate barriers in place, contaminated air exhausted/filtered, ventilation protected, and proper debris removal. The construction IP conducted rounds utilizing the tracer tool to ensure all elements of the ICRA were met and implemented. Following the rounds, immediate feedback was provided to the project managers and contractors.

Results: Use of the tracer tool began in October 2021. The number of tracers completed depends on the active projects at each facility. A total of 53 tracers were completed using the new tool. Immediate feedback is provided to the project managers and contractors. Summary data are presented by quarter to the construction management team. Overall compliance for October 2021 – September 2022 was 96.2% and varied by facility. Compliance for October and November 2022 was 100%.

Conclusions: Creating a home grown tracer tool using the JCR tracer software allowed for organized collection of data and analysis of findings, prompting construction personnel to prioritize safety issues that required immediate attention. As a result of utilizing the tool, a better partnership developed between IPC and construction personnel. Engaging and educating construction team during rounds allowed for long term buy-in to maintain standards and expectations.