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American Journal of Infection Control 40 (2012) 296-303

Contents lists available at ScienceDirect

American Journal of Infection Control

American Journal of
Infection Control

journal homepage: www.ajicjournal.org

Commentary

Competency in infection prevention: A conceptual approach to guide current and


future practice
Denise M. Murphy RN, MPH, CIC a, *, Marilyn Hanchett MA, CIC b, Russell N. Olmsted MPH, CIC c,
Michelle R. Farber RN, CIC d, Terri B. Lee MSN, CIC e, Janet P. Haas DNSc, CIC f, Stephen A. Streed MS, CIC g
a

Main Line Health System, Bryn Mawr, PA


APIC, Washington, DC
Saint Joseph Mercy Medical Center, Ann Arbor, MI
d
Mercy Community Hospital, Coon Rapids, MI
e
Charleston Area Medical Center, Charleston, WV
f
Westchester Medical Center, New York, NY
g
HealthPark Medical Center, Fort Myers, FL
b
c

Key Words:
Competence
Competency model
Professional development
Career stages

Professional competency has traditionally been divided into 2 essential components: knowledge and
skill. More recent denitions have recommended additional components such as communication, values,
reasoning, and teamwork. A standard, widely accepted, comprehensive denition remains an elusive
goal. For infection preventionists (IPs), the requisite elements of competence are most often embedded in
the IP position description, which may or may not reference national standards or guidelines. For this
reason, there is widespread variation among these elements and the criteria they include. As the demand
for IP expertise continues to rapidly expand, the Association for Professionals in Infection Control and
Epidemiology, Inc, made a strategic commitment to develop a conceptual model of IP competency that
could be applicable in all practice settings. The model was designed to be used in combination with
organizational training and evaluation tools already in place. Ideally, the Association for Professionals in
Infection Control and Epidemiology, Inc, model will complement similar competency efforts undertaken
in non-US countries and/or international organizations. This conceptual model not only describes
successful IP practice as it is today but is also meant to be forward thinking by emphasizing those areas
that will be especially critical in the next 3 to 5 years. The paper also references a skill assessment
resource developed by Community and Hospital Infection Control Association (CHICA)-Canada and
a competency model developed by the Infection Prevention Society (IPS), which offer additional support
of infection prevention as a global patient safety mission.
Copyright 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc.
Published by Elsevier Inc. All rights reserved.

The conceptual model (Fig 1) is presented as a circular diagram.


At its center is patient safety, the aspirational goal for everything
else that moves outward from it.
The infection preventionist (IP) specic core competencies are
dened by the Certication Board of Infection Control and Epidemiology (CBIC). The major content areas for the core competencies
are described in Table 1 and correspond to the content outline of
the certication in infection control (CIC) examination.1

* Address correspondence to Denise M. Murphy, RN, MPH, CIC, Vice President,


Quality and Patient Safety, Main Line Health System, 130 South Bryn Mawr Avenue,
Bryn Mawr, PA 19010.
E-mail address: MurphyD@mlhs.org (D.M. Murphy).
Conicts of interest: None to report.

These evidence-based competencies are reective of current


practice and are updated at least every 5 years through extensive
survey research of actively practicing, certied IPs.2 The Association
for Professionals in Infection Control and Epidemiology, Inc (APIC)/
Community and Hospital Infection Control Association (CHICA)Canada professional and practice standards, published in 1999,
identied similar competencies.3,4 This white paper is meant to
serve as an ongoing platform upon which the assessment of IP
knowledge and skills are based; it is a critical element in understanding the IP role as it exists now.5
Extending outward are 4 specic domains that represent
the areas that the APIC has identied for future-oriented competency
development: leadership, infection prevention and control, technology, and performance improvement/implementation science.
Focusing on these 4 strategic developmental domains enables the IP

0196-6553/$36.00 - Copyright 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.ajic.2012.03.002

D.M. Murphy et al. / American Journal of Infection Control 40 (2012) 296-303

297

Fig 1. APIC competency model for the infection preventionist.

to build on the core competencies thereby advancing his/her career


from novice to expert. Progress within the domains is not expected to
occur simultaneously nor be maintained at similar levels at all times.
For example, the IP may demonstrate advanced competency in
technical skills but be less procient in performance improvement
methods or be an experienced leader yet have basic technological
skills. For examples of how to self-dene the IP career stages, see
Table 2.
It is also important to acknowledge that the 4 future-oriented
domains are not mutually exclusive. Just as they are linked to the
core competencies, they are also linked to one another. However, to
help clarify the model, this description emphasizes their unique
aspects as well as the areas of intersection.
To understand better the 4 domains and their implications for
practice, a brief description of each is provided. These descriptions
serve an as overview; additional details and specic content for
each will be developed by the APIC in the future. Member
involvement in this process will be encouraged to assure that the
elements of the conceptual model that are based on expert
consensus reect the dynamic nature of the evolving IP role.

DOMAIN 1: LEADERSHIP
IPs leadership is based on inuence rather than authority, and
this inuence is a consequence of skills in the 5 content categories
described below:
 Collaboration
As team member, facilitator, or leader of multidisciplinary
improvement efforts, the IP serves as champion for a safety
culture where prevention of health care-associated infections
(HAIs) is everyones responsibility. Managing competing agendas
and priorities, while encouraging integration of prevention
activities into the work of every department, takes a skilled
negotiator. Team and consensus-building skills are critical:
Effective team building requires situational awareness, relationship management, networking, marketing, and verbal and written
communication skills. Inuence and persuasion are especially
important aspects of the IPs role in driving change through
partnerships.

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Table 1
Infection prevention core competencies identied by CBIC
Identication of infectious disease processes

Surveillance and epidemiologic investigations

Preventing/controlling the transmission of infectious agents

Employee/occupational health

Management and communication (leadership)

a. Differentiate among colonization, infection, and contamination


b. Identify occurrences, reservoirs, incubation periods, periods of communicability, modes of
transmission, signs and symptoms, and susceptibility associated with the disease process
c. Interpret results of diagnostic/laboratory reports
d. Recognize limitations and advantages of types of test used to diagnose infectious processes
e. Recognize epidemiologically signicant organisms for immediate review and investigation
f. Differentiate among prophylactic, empiric, and therapeutic use of antimicrobials
g. Identify indications for environmental microbiological monitoring
a. Design surveillance systems
b. Collect and compile surveillance data
c. Interpret surveillance data
d. Conduct outbreak investigation
a. Develop and review infection prevention and control policies and procedures
b. Collaborate with public health agencies in planning community responses to biologic agents
(eg, anthrax, inuenza)
c. Identify and implement infection prevention and control strategies related to the following:
1. Hand hygiene
2. Cleaning, disinfection, and sterilization
3. Specic direct and indirect care settings
4. Infection risks associated with therapeutic and diagnostic procedures and devices
5. Recall of potentially contaminated equipment and supplies
6. Initiation and discontinuation of isolation/barrier precautions when indicated
7. Patient placement, transfer, and discharge
8. Environmental hazards
9. Use of patient care products and medical equipment
10. Immunization programs for patients
11. Construction and renovation in patient care
12. The inux of patients with communicable diseases
a. Review and/or develop screening and immunization programs
b. Provide counseling, follow-up, work restrictions, and recommendations related
to communicable diseases or following exposures
c. Assist with analysis and trending of occupational exposure incidents and information
exchange between Occupational Health and Infection Prevention and Control departments
d. Assess risk of occupational exposure to infectious diseases
Planning
a. Conduct an infection risk assessment of the organization
b. Develop, evaluate, and revise a mission and vision statement, goals, measurable objectives, and
action plans for the infection prevention and control program
c. Recommend specic equipment, personnel, and resources for the infection prevention and
control program
d. Participate in cost benet assessments, efcacy studies, and product evaluations
e. Recommend changes in practice based on clinical outcomes and nancial implications
Communication and feedback
a. Provide infection prevention and control ndings, recommendations, annual reports, and
policies and procedures to appropriate individuals, committees, departments, and units
b. Communicate with internal and external customers
c. Collaborate with risk management/quality management in the identication and review of
adverse and sentinel events
d. Evaluate accreditation/regulatory issues and facilitate compliance

Education and research

Quality/performance improvement and patient safety


a. Participate in quality/performance improvement and patient safety activities related
to infection prevention and control
b. Demonstrate quality/performance improvement projects through the use of graphic tools
Education
a. Assess needs, develop goals and measurable objectives, and prepare lesson plans for educational offerings
b. Apply principles of adult learning to educational strategies and delivery of educational sessions
c. Prepare, present, or coordinate educational workshops, lectures, discussion, or one-on-one
instruction on a variety of infection prevention and control topics
d. Evaluate the effectiveness of education and learner outcomes
e. Instruct patients, families, and other visitors about methods to prevent and control infections
Research
a. Apply critical reading skills to evaluate research ndings
b. Incorporate research ndings into practice through education and consultation

NOTE. For a detailed description of competencies, see the 2012 CBIC examination content outline.1

 Followership
Effective teams need leaders, and, in turn, these leaders need
followers. IPs serve a supportive (follower) role when interdisciplinary teams are formed to prevent infections. This followership
role allows the IP to provide expertise and exert inuence in the

absence of direct or traditional authority. Attributes of effective


followers include strong critical thinking skills, passionate
commitment to the mission, active engagement, positive energy,
and a willingness to challenge leaders and offer constructive criticism.6 By illustration, Grint stated that, the power of leaders is
a consequence of the actions of followers rather than a cause of it.7

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299

Table 2
Descriptions and examples to assist with self-denition of IP career stage
Examples of competencies demonstrated across the career span
Novice IP
Conducts surveillance: standardized, basic case
nding methods and application of HAI denitions
Is learning to use NHSN
Performs manual record/chart review, data
abstraction, and data collection

Conducts infection rate calculations and basic


statistical analysis (mean, median, rate, ratio)

Is able to do graphic data display and report


generation and dissemination
Benchmarks/compares rates

Possesses basic knowledge of epidemiology and


outbreak investigation; can assist with
investigations but usually does not lead them

Uses literature review as an essential tool

Uses data to identify the need for change and can


propose basic intervention/improvement projects
Is learning the essential skills of PI and IS
Understands and performs basic team/project
facilitation and application of PI/IS skills
Understands adult education principles, can design
educational programs, and has effective
presentation skills
Develops policies and procedures based on
understanding of regulatory/accreditation
requirements

Participates in committee and program support (eg,


IPC committee agenda planning and facilitation,
IPC program risk assessment/action plan)

Procient IP (all in column 1 plus)

Expert IP (all in columns 1 and 2 plus)

Can apply and expand surveillance principles to


diverse populations
Skilled at using NHSN and may validate NHSN
surveillance conducted by others
Independently performs electronic surveillance,
applies data mining principles, and can integrate
both manual and electronic ndings for
comprehensive reporting
Uses more advanced statistical tools (SIR, P values,
standard deviation, odds ratio)
Able to interpret research data and apply ndings to
current practice
Understands and/or uses more complex data display
tools (control charts, afnity diagrams, scatter
plots)
Possesses understanding of endemic vs epidemic
rates, common or special cause variation
Uses comparative analysis to support institutional
accrediting, regulatory compliance, and others
Has more advanced knowledge of epidemiology and
study design; can conduct basic cluster/epidemic
investigations
Collaborates with the local/state health department,
as needed
Interprets and applies meta-analyses; interprets
research ndings, identies study limitations and
bias
Can design complex interventions, understands and
applies principles of PI and IS to both daily
operations and special projects

Identied as expert in specialty areas such as public


health, outpatient settings, research, or consulting
Has the ability to confer with the CDC and other
stakeholders in ongoing development of NHSN
Expert in e-surveillance, use of EMR/other technology
Applies principles of information management to
emerging technology

Independently uses PI and IS tools and methods; can


chose and utilize approaches appropriate to
stakeholder needs and project timelines
Is an effective educator/presenter using a variety of
skills and techniques
Has experience with presenting to large audiences
(internal and/or external)
Participates in local, regional, national policy review,
advocates for legislation (eg, comments on pending
IPC legislation, meets with legislators)
Knowledgeable about accreditation and other quality
requirements pertaining to infection prevention
and control
Participates and/or leads goal planning activities,
program assessment, budget development, or staff
management; can make effective business case for
needed resources

Applies statistical methods in study design and


research activities (sampling, power, hypothesis
testing)
Develops/uses complex data tables; teaches others to
rene data display and reporting skills
Integrates comparative analysis into high level,
strategic understanding of facilitys quality, safety,
and risk mitigation programs
Can design and conduct complex studies/
investigations, including across institutions
Collaborates with CDC on specic events, publishes
results
Adds to the body of published literature
Highly skilled at reviewing, interpreting, and applying
research nding
Uses principles of inuence, leadership, and change
management
Effectively negotiates for optimum collaboration and
resource allocation for IPC initiatives
Designs, facilitates, or leads multidisciplinary team
projects; is a recognized expert in PI/IS with
successful outcomes
Is a recognized expert, experienced in presenting to
national and/or international audiences
Serves as a role model; coaches others
Actively inuences local, regional, national IPC
agenda, writes policy, standards, or guidelines and
lobbies for/against legislation.
Consults with accrediting bodies and other
stakeholders regarding development of standards,
measures, and metrics
Participates or facilitates strategic planning activities
related to IPC or patient safety/quality, recognized
as organizational/community or national leader

EMR, electronic medical record; IPC, infection prevention and control; IS, implementation science; PI, performance improvement; SIR, standardized infection ratio.
NOTE. Early career/novice: The novice IP is employed in a health care setting where infection prevention is the primarydalthough not always the soledfocus of the role.
The novice is often earning or has earned a baccalaureate degree and is developing a basic skill set and knowledge base but is not yet prepared to sit for the certication exam
(CIC). Novice IPs are actively acquiring fundamental infection prevention and control skills with emphasis on learning how to do surveillance and effective reporting, basics of
epidemiology and statistics, adult education principles, policy development, and committee planning and support. They are working to understand and shape their role as an
organizational patient safety leader.
Mid-career/procient: The procient IP has earned an undergraduate degree and is often pursuing post-baccalaureate education. The procient IP may have management or
supervisory responsibility. This IP has earned certication and may serve as mentor for those pursuing the credential. Procient IPs have a diverse skill set, demonstrate critical
thinking, and function successfully in team-based, collaborative situations. They have further developed and are rening their leadership skills and are effectively managing
their IPC program. Procient IPs are highly skilled and professionally condent in their roles as preventionists and patient safety advocates.
Advanced/expert: The advanced IP is earning or holds a graduate degree. His or her professional activities may showcase expertise in leadership, management, education,
consultation, advanced analysis, strategic planning, and multiple other competencies appropriate to the specic type of role. The expert IP also promotes certication, mentors
others, and demonstrates the value of the credential through advanced knowledge and skills. The expert IP is an accomplished, recognized leader and patient safety champion
in their own organization, whose collaborative inuence may reach beyond their employer/business to regional, national, and international audiences.

 Program management
Alignment of the infection prevention programs goals with the
organizational strategic priorities and annual operating plan is an
important responsibility for every IP. Whether in a formal or informal managerial role, the IP must oversee daily prevention activities
and the budget and allocate personnel and other resources while

constantly balancing workload with patient-focused priorities.


Concurrently, the IP must remain sensitive to the organizations
culture and emotional intelligence (EI), as well as to the many
competing priorities that can impact desired clinical and operational outcomes. The program and staff must be able to rapidly
respond to shifts in regulatory and accreditation requirements or
emerging science through a nimble adaptive management style.

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Innovation applies to many aspects of leadership, including the


ability to effectively and efciently manage the infection prevention and control (IPC) program.
Preventionists must also understand the economic environment, the impact of changing payment trends, quality-based
incentives, and how HAIs specically erode the organizations
nancial health. This knowledge provides the basis for making the
business case for improved or continued support of a patientfocused IPC program.
Planning, both strategic and operational, is a necessary skill to
keep the program goals high on the organizational priority list.
A key element of planning is the ability to forecast the need for new
services that will change the workload and proactively identify
resources required for success. Resources can be program staff or
partners, access to key decision makers, technology, or other
infrastructure that will help organize, drive, and complete work.
Effective program management also involves the ability to create
action plans with explicit time lines for deliverables and responsible parties accountable for certain tasks.
 Critical thinking skills
Critical thinking is a process or method of understanding the
problems or questions at hand, as well as challenging assumptions
and considering alternative perspectives. In the context of IPC, this
domain is about being procient at understanding, utilizing and
synthesizing scientic evidence, including methods for translating
evidence into practice. This is an intellectual competency that
focuses on goals, outcomes, and organization-wide impact of
prevention initiatives. Judgment, reection, complex reasoning,
and analysisdalong with professional insight and wisdomdare all
necessary aspects of this skillset.
Interpersonal skills. Critical thinking links with EI, another
characteristic of effective leaders.8 EI is dened as self awareness and
the ability to manage the emotions of self and others toward effective partnerships. It includes having social skills and an empathetic
approach to people and being able to inspire, inuence, and develop
others. The IPs ability to think critically, coupled with keen interpersonal skills, support all other aspects of successful leadership.
 Communication
The ability to inuence, serve as a role model, demonstrate
accountability and integrity, and communicate the value of infection
prevention to a diverse audience to achieve desired outcomes are all
required for leadership competency. Communication (verbal and
written) may, in fact, be the most critical element of successful organizational leadership. Effective communication takes into account the
audiences informational needs, their cultural background, and
knowledge of the subject. Being concise, accurate, and timely in
communicating critical information is a skill taught in conjunction
with the science of safety and a much-needed competency for IPs.
Understanding barriers to effective communication is as
important as knowing how to communicate well. Barriers may be
physical, psychological, attitudinal, cultural or linguistic, or because
of the volume and complexity of information being shared. Careful
audience assessment and calibration of the message accordingly is
an important strategy for reducing barriers to effective transfer of
information. The art of inuence and persuasion is also directly
linked to communication competencies.
DOMAIN 2: IPC
IPC competencies are the foundation of the IPs development.
IPs are subject matter experts in the epidemiology and natural

history of infectious processes and pathogens, recognition of clusters and risk factors for infection, and methods for breaking the
chain of infection. The core competencies identied by CBIC are
essential. Simultaneously, the dynamic nature of the profession
requires additional focus in the following areas:
 Epidemiology and surveillance
The ability to apply surveillance denitions and methodologies
(ie, from the Centers for Disease Control and Preventions National
Healthcare Safety Network [CDC NHSN] or McGeer et al9 for longterm care surveillance) is essential to the development of collection tools and gathering of relevant surveillance data. The IPs
prociency at understanding and selecting appropriate benchmarks for comparison, as well as literature review, supports
a proactive approach to setting infection reduction targets and
thresholds upon which they may need to react (eg, if rates are
higher than internal baseline measures or external benchmarks).
IPs must appropriately select, calculate, and explain rates (eg,
incidence, prevalence) and ratios (eg, standardized infection ratio).
IPs generally review a basic data set, often displayed on run
charts, to establish general impressions of a measured process or
outcome. Information is the result of further processing of data,
beginning with univariate analysis (eg, calculation of mean,
median) and comparison against benchmarks. Run charts may be
further interpreted using runs rules to identify trends and special
cause variation, which could indicate the need for further investigation. More advanced analysis may employ the use of statistical
process control charts where processes (or outcomes) are described
with upper and lower control limits in addition to univariate
descriptive statistics.10 Statistical concepts such as power should be
understood when determining adequate sample size to establish
statistical signicance between/among comparison groups. IPs
must also know when and how to use hypothesis testing.
 Risk assessment
The IP leads the organization in application and evaluation of
basic institutional risk criteria such as that used in hazard
vulnerability analysis (eg, current magnitude of the problem,
current ability to control the problem, risk to patients) for specic
situations and uses relevant data and methods to align the infection prevention plan with the results of the risk assessment. An
example would be evaluating risk for Clostridium difcile infection
in an institution. The organization should assess whether this is
a high priority area for them by comparing the rate of incident
infections provided by the IP with an internal or external benchmark and would then decide whether additional risk reduction
strategies might be appropriate. These could involve changes in
isolation practice, testing methods, or collaboration with facilities
in the catchment area of the institution on risk reduction.
Conversely, the organization could decide that the rate is low
enough that current processes are appropriate and could give this
topic a low priority in the assessment. When interventions are
planned, the IP must make sure that they are measurable, appropriate, objective, and valid.
 Risk reduction and infection prevention
IPs are involved in reducing infection risk throughout various
health care settings. This includes consultative input into the
physical design of patient care environments and establishing
specications for protective measures during construction and
renovation. IPs also play a key role in the evaluation of new
procedures and clinical technologies for patient care. In addition,

D.M. Murphy et al. / American Journal of Infection Control 40 (2012) 296-303

IPs monitor conformance with care processes that are correlated


with decreased infection risk. Understanding and blending institutional processes and systems with validated risk reduction and
error prevention strategies are crucial for improving patient care
and employee safety.
 Use and interpretation of diagnostic tests
The IP must be familiar with complex testing methods that
include polymerase chain reaction, probe-based tests for nucleic
acid sequencing, molecular typing, and interferon g release assays
for tuberculosis detection. They must be able to articulate the
advantages and disadvantages (especially in terms of test sensitivity and specicity) of diagnostic tests for potential use in their
setting.
 Antimicrobial stewardship
Antimicrobial stewardship (AS) is an interprofessional effort that
involves optimal, prudent antimicrobial use for patients across the
continuum of care: acute, inpatient, long-term care, and outpatient
settings. The goal of AS programs is to improve the therapeutic use of
antimicrobials through education of clinicians, guidelines, computer
decision support, and de-escalation based on culture results. IPs can
support AS programs by helping to provide surveillance for
syndromes of interest, implementing interventions to guide the
delivery of evidence-based practices, and translating data from
antibiograms and antibiotic utilization along with infection rates for
health care personnel, nursing units, and administrators.11
 Education
The IP remains a resource for patients and staff in the area
of education. However, new approaches will be needed to meet
the learning needs of an increasingly diverse workforce. Prociency in the use of age-adjusted interactive learning techniques,
simulation-based training, clinical decision support tools, and
just in time education will be signicant additions to existing
training competency.
 Research
The IP must be able to critically evaluate research and apply the
ndings to their practice setting. The ability to understand and
interpret research methodologies, including interrupted time
series, retrospective case-control, cluster randomization, and
prospective longitudinal studies, is important. In addition, IPs who
have the resources, time, and inclination should participate in
research, present abstracts on results, and subsequently author
manuscripts for publication in peer-reviewed professional and
scientic journals.
DOMAIN 3: TECHNOLOGY
Surveillance of HAIs requires systematic data collection, collation, analysis, and dissemination of key ndings to providers to
improve performance. The rapid escalation in the demand for HAI
data highlights the critical need for IPs to use and advocate for
standardized, validated, and reproducible data. Managing these
critical data will increase demands on the IP (ie, the burden of
surveillance) especially because this is typically accomplished by
manual processes. Even so, an important caveat to use of electronic
patient and laboratory data is illustrated in the sentiments of
a preventionist using advanced surveillance technology, . . .
a surveillance system itself does not reduce infections . . . neither do

301

the infection preventionists (alone). (Patient care) practices reduce


infections. Technology allows us to get out on the oors and work
with (patient care teams) more . . . 12
To address growing demands for procurement of HAI data as
efciently as possible, better IP knowledge and skills in use of
surveillance technology and health informatics will be necessary.
While this is a highly dynamic domain, IPs must be prepared to
address the following that include but are not limited to:
 Information technology support
Professional and practice standards and elements of board
certication in infection prevention assume preventionists will
have access to information technology (IT) hardware and be procient in use of associated applications (eg, word processing,
spreadsheets, presentation and communications applications, the
health system intranet). To accomplish surveillance, the preventionist also needs access to key clinical and administrative
databases such as patient information (eg, electronic medical record
[EMR]) and laboratory information systems, admission/discharge/
transfer (ADT), patient bed assignment/management (eg, bed
boards), surgery information system, and, possibly other correlate
databases such as pharmacy (eg, utilization of antibiotics) and
radiology (eg, verication of presence of a central line in chest X-ray
reports). IPs often will need to request assistance from IT professionals for access to and reports from these and other databases.
Therefore, they need to clearly communicate these requests and
clarify throughout the development of reports to make sure the
output is understood when received and as intended. Once received,
it will be important to validate automated reports both initially and
periodically thereafter to verify consistency of report accuracy. By
illustration, tabulation of device days may vary considerably by data
source used (eg, nance report, EMR, manual tally by unit
personnel), so validating report accuracy and integrity is important.
In the United States, this importance escalates with state-specic
requirements and recent federal pay-for-performance incentives,
wherein reimbursement is tied directly to patient outcomes,
including HAIs. This effort has resulted in mandatory reporting of
certain HAIs to the CDCs NHSN.13
Effective use of the NHSN will necessitate valid data input, and
IPs will need to complete training in the use of NHSN prior to
sending data to the NHSN. This network will continue to be the
centralized technology platform for collection, analysis, and
reporting of HAI data in the United States. Technology is also
increasingly being used to collect data on adherence with infection
prevention processes via a portable device (eg, hand hygiene and
isolation precautions) or more advanced infrastructure that automates observation entirely.14-16
 Surveillance technology
More advanced analytical tools are increasingly important to
support surveillance. These include data mining services that use
interfaces among laboratory information systems, ADT, pharmacy,
and other health information databases. Such tools can detect
clusters of epidemiologically important pathogens, create automated alerts of newly detected multidrug-resistant organisms, and
improve efciency and scope of review and analysis of large
quantities of data.17 Some surveillance technology can also provide
decision support to clinicians regarding use and selection of
antimicrobial agents.18 Vendors for these applications have also
collaborated with the NHSN to support seamless, automated
transfer of data into the NHSN. This capability is beginning to be
used but still requires considerable collaboration among the
vendors, the IP, and the IT professionals to realize full functionality.

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With the transition from manual methods, the IP must be


prepared to understand and convey to partners the meaning of
a fully automated transmission of HAI data done seamlessly by
computer. This direction will likely have substantial impact on the
process of surveillance, but effective use of these data will be
dependent on the IPs skills and understanding of the strengths
and limitations of output from automated HAI detection systems
or their proxies. The benet of this emerging use of IT is reallocation of the preventionists time from data entry to intervention
strategies aimed at prevention in collaboration with direct care
team members. Preliminary evidence indicates that EDWs can
be used for algorithmic detection of HAIs, such as central lineassociated bloodstream infection and ventilator-associated
complications.19 The challenge for IPs and health care epidemiologists is to assure automated surveillance provides meaningful
information upon which actions to improve care and safety can
be taken.20
 EMR and EDW
Currently, only 12% of health systems in the United States have
a fully functional EMR as dened by key attributes such as
computerized provider order-entry and clinical care documentation. There are national initiatives to transition all clinical documentation, such as laboratory testing and imaging reports, to
a common electronic platform spanning the spectrum of care. IPs
will need to be involved as early as possible in the evaluation and
selection of an EMR vendor to assure that it provides meaningful
use as dened by the needs of the HAI surveillance program. Use
of EMR can include automated collection of device-days for all
patient units, alerts to clinicians of continued presence of devices
such as urinary catheters, real-time management of patients in
isolation precautions, and names of personnel needing postexposure follow-up from possible occupational exposure to
infectious disease.21,22 EDW can serve as a repository of data from
a range of databases and information systems that can be queried
for impact of certain infections on resource utilization (eg, length
of stay), effectiveness of infection prevention and therapeutic
interventions, algorithmic detection of possible HAIs, syndromic
surveillance for public health or national security reasons, data
validation, and identication of possible surgical site infections
coded in claims data systems.
DOMAIN 4: PERFORMANCE IMPROVEMENT AND
IMPLEMENTATION SCIENCE
Performance improvement encompasses all of the systems,
projects, and team activities an organization implements to achieve
its goals. These goals include the prevention of HAIs for patients,
visitors, and staff.
Implementation science (IS) is the scientic study of methods
to promote the systematic uptake of clinical research ndings and
other evidence-based practices into routine practice and hence to
improve the quality (effectiveness, reliability, safety, appropriateness, equity, efciency) of health care. It includes the study of
inuences on health care professional and organisational behaviour.23 Therein, Eccles et al23 aptly describe the work of IPs. IS
provides a conceptual basis for translating evidence into practice,
addressing gaps between theory and practice, and serves as a useful
clinical model to accomplish improvement in safety, quality, and
effectiveness of patient care.
Performance improvement (PI) methods and the principles of IS
must be fully integrated into prevention program operations. If PI
and infection prevention functions are separated within an organization, there must be sufcient coordination and communication

between them to maintain successful partnerships. To accomplish


performance/process improvement aimed at reduction of HAIs, the
following 5 elements are required:
 Identication of need for PI
The IP is skilled at identifying timely and relevant improvement
opportunities, using measures and data to support improvement
projects, and creating a PI charter outlining the scope of activity to
be initiated.
 Assembly of PI team
The IP has sufcient knowledge, skill, and experience to function
in several key PI roles: team leader, facilitator, or team member.
Selecting team members best able to help achieve desired
outcomes is one of the most critical aspects of improvement work.
Equally important is the selection of a clinical champion and
executive sponsor whose responsibilities include removal of
barriers and allocation of resources.
 Tools and methods
The IP has sufcient knowledge, skill, and experience to use and
apply the organizations preferred PI tools (eg, PDSA [Plan, Do,
Study, Act], Lean, Six Sigma), as well as principles of IS, to infection
prevention activities.
 Implementation
The IP has sufcient knowledge, skills, and experience to
effectively utilize a well-described conceptual model that uses the 4
core elements of engagement, education, execution, and evaluation
to move research into prevention practices.24 Key IS skills for the IP
to master include identication and critical analysis of scientic
evidence, synthesis of interventions with the greatest benet,
identication of barriers to successful implementation, and innovative approaches to remove barriers.
 Measuring success
Performance measurement is important to establish baseline
performance and ensure that all patients are receiving the targeted
interventions and that interventions are sustained over time. The IP
prociency in measurement includes baseline analysis (comparison against appropriately matched benchmarks), selection of goals
with challenging but achievable targets, and process and outcome
measurement appropriate to the improvement project. The IP must
demonstrate the ability to evaluate the achievement of project
goals and relate those achievements to concrete improvements in
clinical outcomes. In turn, the business case for infection prevention, the support of regulatory or accreditation compliance, or other
outcome reporting requirements follow naturally.
COMPETENCY AND CERTIFICATION
Achievement and maintenance of certication in infection
prevention and control (CIC) is one of the APICs and CHICAs
strategic priorities for all professionals engaged in IPC. The CIC
credential denotes mastery of fundamental knowledge required for
competent performance of current infection prevention practice.
Board certication in infection prevention is critical to professional development. It represents the bridge between the novice
and the procient professional. Although this transition is not
readily quantied by years of practice, experience remains an

D.M. Murphy et al. / American Journal of Infection Control 40 (2012) 296-303

important teacher and source of skill development as the IP progresses along the professional development path.
The certication examination is based on the core competencies
summarized in the Examination Content Outline in the CBIC
Candidate Handbook. The core competencies comprise the most
fundamental aspect of the model. The future-oriented domains are
included only to the extent that they correlate to the current
research-based ndings used to identify the core competencies.
USING THE CONCEPTUAL MODEL
IPs who use organizational-specic competency denitions or
worksheets (eg, position descriptions) can begin by comparing the
existing tools with this model (refer to Fig 1). In doing so, they can
determine to what extent they are similar or different and can
assess if APICs future-oriented domains are identied. If they are
not, a discussion with leadership on how they can be included may
prove useful. The competency model provides an excellent tool for
discussion among all institutional stakeholders and can be a practical resource in helping educate others about the overall aspects of
the IPs expanding role.
At the same time or in conjunction with annual goal-setting
activities, IPs can perform a self-assessment of individual knowledge and skills and compare it to the domains and categories
described herein. The IP will quickly identify areas in which further
education or skills development are needed and can integrate these
domains into their own plans for professional development.
The model can also serve to help inform and guide new IPs. It
can be used as a general map for career planning and help direct
those with less experience into areas where future knowledge and
skills will be most needed and valued.
Competency is a broad and complex topic, which is relevant to
all IPs. Describing a model, endorsed and accepted by its constituents, is inherent to the denition of the professional role. The
competencies were developed by IPs active in the elddworking in
diverse settings in the United States and internationallydwho
serve on boards, leadership committees, and multidisciplinary task
forces focused on prevention of HAIs. The APIC views the model as
part of the Associations long-standing efforts to dene and
advance the profession. Future efforts will build on the initial phase
of development described in this white paper.

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Acknowledgment

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In addition to the authors of this white paper, the APIC wishes to


thank the members of 2010-2011 Infection Preventionist Competency Task Force who contributed signicantly to this project: Amy
Richmond, RN, BSN, MHS,CIC; Clifton Orme, MBA; Sue Barnes, RN,
CIC; Cathryn Murphy, RN, PhD, CIC; and Anne Bialachowksi, RN, BN,
MSc, CIC.

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References

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