Abstract
ISSUE: As part of the system's commitment to quality program, hospital infection prevention and control programs were evaluated to assess compliance with nationally accepted standards of care and patient safety. One important outcome of the collaborative effort was the development of an infection prevention and control hospital resource plan that could be implemented across the system. PROJECT: The model infection control program plan was created as a framework to assist tenet hospitals in the development of their infection control programs. The goal of the model infection control program plan was to provide a minimum outline of what should be included in each and every infection control program in the system. The model plan encompasses the 2005 regulatory requirements from the Centers for Medicare and Medicaid Conditions of Participation; the 2005 Joint Commission on Accreditation of Healthcare Organization Standards for Practice; and the position statements about infrastructure and essential activities of infection control and epidemiology programs in hospitals from the combined Society of Healthcare and Epidemiology and the Association of Professionals in Infection Control and Epidemiology Consensus Panel Report. RESULTS: In January 2004, a pilot implementation of the model plan was initiated at 14 of the system's Florida hospitals and has been in operation for 13 months. There was no known resistance to implementing the plan. Infection control practitioners did report an increased confidence in individual hospital program plans as a result of this project. Following a successful introduction of the pilot, a model plan that could be implemented company-wide was drafted and subsequently modified (see below). The model plan has been approved and will be introduced to all hospitals by the end of January 2005. LESSONS LEARNED: Because the pilot plan was developed in Florida, it reflected state-specific requirements that were not generalizable to hospitals across the country. Therefore, the plan was modified with a focus on making it as comprehensive as possible, while maintaining flexibility so that it could be tailored to meet the needs of specific hospitals and specific regions. Involving the legal department was important in the development of the plan and is crucial to any hospital implementing a model plan for use nationwide, because legal counsel can ensure that the plan will comply with medical staff bylaws and laws of individual states.
Published Version
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