SELF- AUDIT TOOL for. Infection Prevention and Control Professional

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1 Name of Facility: Date: YYYY MM DD Time: hours / AM PM ICP (print): Signature: Abbreviations: CIC Certification in Infection Control ICP Infection Prevention and Control Professional IP&C Infection Prevention and Control OH&S Occupational Health and Safety Audit Toolkit supported in part by Virox Technologies Inc. Revised November 16, 2010 Audit Toolkit Version 2, September 2009 CHICA-Canada Page 1

2 Glossary: Certified in Infection Control (CIC ): A credential obtained from the Certification Board of Infection Control and Epidemiology, Inc. (CBIC) following the successful completion of a written examination. Recertification is required every five years to maintain certification. More information may be found on the CBIC website: CIC is a legal designation and may only be used by those who have attained and maintained certification. CHICA-Canada: The Community and Hospital Infection Control Association of Canada, a professional organization of persons engaged in infection prevention and control activities in health care settings. CHICA-Canada members include infection prevention and control professionals from a number of related specialties including nurses, epidemiologists, physicians, microbiology technologists, public health and industry. The CHICA-Canada website is located at: Outcome Surveillance: Surveillance used to measure client/patient/resident outcomes (changes in the client/patient/resident s health status that can be attributed to preceding care and service). An example of outcome surveillance related to infection prevention and control is surveillance of infection rates. Outcome surveillance reflects the efficacy of the infection prevention and control program in protecting clients/patients/residents, health care providers and visitors from health care-associated infections while decreasing costs from infections. Process Surveillance: Surveillance used to assess or measure client/patient/resident processes (things done to or for a client/patient/resident during their encounter with the health care system). An example of process surveillance related to infection prevention and control is planned audits to verify that procedures and/or standards of practice are being followed. Audit Toolkit Version 2, September 2009 CHICA-Canada Page 2

3 The purpose of this tool is to assist professionals to identify areas in their practice that are strengths and learning opportunities that will assist in the development of a learning plan for the next year. Overview: Individuals can and should do a self-assessment to identify the knowledge and skills they need to obtain or strengthen. Such self-assessment might be done formally (e.g., as part of a performance appraisal) or informally. Areas for development might be specific to infection prevention and control, or may be more generic, such as improving written or verbal communication, ability to work in a team, or finding and appraising research evidence. This self-audit tool of practice may be used by an individual Infection Control Professional (ICP) to identify knowledge and skill sets that need to be developed. Setting learning goals will provide an overall direction for learning. Goals should be concrete enough to guide behaviour/knowledge changes and may be either short-term or long-term in nature (or both). Target dates should be included when setting goals. Progress toward meeting learning goals should be evaluated on a regular basis. How to Use This Audit Tool: In Section 1 of the audit tool, answer Yes if the statement is true or if you have completed the task, and answer No if the statement is untrue or if you have not completed the task. In Sections 2 to 15 of the audit tool, read each statement and then determine at which practice level you perform the element, using Table 1 as a guide to the practice levels. For example, if you are a new ICP with less than a year of experience you might score #2.4 ( I participate in professional organizations and networking opportunities, e.g., CHICA-Canada ) at the Developing level, as you might only have attended a few local chapter meetings. If you have been and ICP for 5 years and are on the executive of a CHICA-Canada chapter you would score this item at the level. The forms in Appendix A and B may be used to develop action plans based on the results of the selfassessment audit of practice. It is recommended that the focus be on areas to which No has been answered in Section 1 or areas identified as or Developing in the remaining Sections, as described in Table 1. Audit Toolkit Version 2, September 2009 CHICA-Canada Page 3

4 Table 1: Interpretation of s Used in Self-Assessment Audit Tool Not Applicable Developing Interpretation A skill or practice that you determine could not be part of your role A skill or practice you do not currently use but which should be included in your role limited understanding of the situation or area of practice clear rules or mentorship/guidance are required for safe practice in this area A skill or practice you feel could be improved demonstrates acceptable performance that could be improved has enough experience to recognize important basic infection prevention and control aspects of a situation or area of practice A skill or practice you feel you are good at has handled similar relevant situations or areas of practice able to distinguish important aspects and prioritize components of items or practices under consideration capable of conscious, deliberate planning in carrying out the skill or practice shows self-confidence and efficiency when carrying out the skill or practice A skill or practice you feel you excel in able to mentor others in this skill or practice has the ability to make rapid and accurate decisions based on knowledge and experience expertise is a hybrid of practical and experiential knowledge Audit Toolkit Version 2, September 2009 CHICA-Canada Page 4

5 Developing Not Applicable SELF- AUDIT TOOL for Element Yes No 1.0 Qualifications, Education, Ethics and Accountability 1.1 I am an experienced health care professional with a health sciences background 1.2 I have completed an infection prevention and control (IP&C) training course that has been endorsed by CHICA-Canada 1.3 I am certified or working toward Certification in Infection Control (CIC ) 1.4 I have maintained Certification in Infection Control 1.5 I maintain confidentiality 1.6 I support my profession s standards/ code of ethics and CHICA-Canada s position paper on the role of the infection control practitioner/professional 1.7 I am knowledgeable, accountable and responsible for my actions 1.8 I practice in a non-judgemental, non-discriminatory manner and am sensitive to diversity 1.9 I recognize and resolve conflict of interest situations 1.10 I engage in IP&C research in a professional manner 1.11 I ensure transparency and disclosure in performing research or applying for grants Element 2.0 Professional Development 2.1 I demonstrate basic knowledge and skills related to IP&C 2.2 I network and collaborate with colleagues in similar job fields frequently 2.3 I collaborate with, and support, others to improve competency in the science of IP&C 2.4 I participate in professional organizations and networking opportunities (e.g., CHICA-Canada) 2.5 I am proactive in my self-development 2.6 I demonstrate professional commitment to keep current in all aspects of infection prevention and health promotion 2.7 I participate in continuing education 2.8 I maintain current knowledge and functionality with electronic media (e.g., computers, hand-held data entry devices) that facilitates communication and practice Audit Toolkit Version 2, September 2009 CHICA-Canada Page 5

6 Developing Not Applicable SELF- AUDIT TOOL for Element 2.9 I perform regular self-evaluations to identify strengths and areas for improvement (e.g., CHICA-Canada s selfaudit tool) 2.10 I seek constructive feedback regarding professional practice from my peers and mentors 2.11 I use feedback and results of evaluations to establish and work towards professional goals and objectives 2.12 I am committed to protecting clients/patients/residents and staff through the support of safe practices and policies 3.0 Leadership 3.1 I provide direction and work collaboratively with others 3.2 I share knowledge and skills with others 3.3 I am creative and innovative in furthering the practice of IP&C 3.4 I monitor IP&C policies, procedures and standards for the organization to ensure compliance with relevant legislation or guidelines applicable to my health care setting 3.5 I seek opportunities to influence and educate policymaking bodies 4.0 Infection Prevention and Control Practice 4.1 I review, analyse and implement regulations, standards and/or guidelines of applicable governmental agencies and professional organizations related to IP&C 4.2 I review, analyse and apply pertinent information from current scientific literature and publications related to IP&C 4.3 I assess the effect of international, national and local trends on IP&C practice 4.4 I acknowledge personal limitations and seek advice from others with specific expertise when necessary 5.0 Microbiology and Infectious Diseases 5.1 I support staff in procedures for specimen collection 5.2 I recognize the limitations and advantages of tests used to diagnose infectious processes 5.3 I seek and interpret microbiological data to assist in the prevention and control of infection 5.4 I review microbiological data to evaluate the efficacy of interventions Audit Toolkit Version 2, September 2009 CHICA-Canada Page 6

7 Developing Not Applicable SELF- AUDIT TOOL for Element 5.5 I interpret results of diagnostic/laboratory reports, assess the clinical relevance of microbiological information and advise accordingly 5.6 I recognize epidemiologically significant microorganisms for immediate review and investigation 5.7 I assess patients, staff, visitors and relatives, environments and situations to estimate the risk of transfer of microorganisms and the likely consequences of such transfer 5.8 I distinguish between modes of transmission of microorganisms and recommend appropriate methods of control 5.9 I differentiate between prophylactic, empiric and therapeutic uses of antimicrobials 5.10 I can identify indications for environmental microbiologic monitoring 6.0 Surveillance 6.1 I have designed and maintained a system of surveillance for health care-associated infections appropriate to my health care setting 6.2 I use indicators that are based on the projected use of the data to be collected 6.3 I use standardized definitions for the identification and classification of indicators, events or outcomes 6.4 I determine the incidence or prevalence of infections in my health care setting 6.5 I utilize information technology and systems applications (e.g., internal and/or external databases) to collect, manage and maintain data 6.6 I analyse surveillance data and calculate risk-adjusted infection rates appropriate to the indicator 6.7 I incorporate post-discharge surveillance findings into the calculation of infection rates 6.8 I report outcome surveillance data back to appropriate stakeholders 6.9 I periodically evaluate the effectiveness of the surveillance plan and modify it as necessary 6.10 I utilize process surveillance audit tools to evaluate best IP&C practices in my facility (e.g., CHICA s audit tools) Audit Toolkit Version 2, September 2009 CHICA-Canada Page 7

8 Developing Not Applicable SELF- AUDIT TOOL for Element 7.0 Epidemiology 7.1 I critically evaluate the significance of surveillance results and compare results to published data or other benchmarks 7.2 I use statistical techniques to describe surveillance data, calculate rates and develop benchmarks 7.3 I report epidemiologically significant findings from surveillance to appropriate stakeholders 7.4 I develop and implement corrective action plans based on surveillance findings 7.5 I use epidemiologic principles to conduct surveillance investigations based on the results of surveillance data 7.6 I initiate an outbreak investigation when required 7.7 I have established mechanisms for identifying those with communicable diseases requiring follow-up and/or isolation 7.8 I integrate surveillance findings into practices that will improve client/patient/resident outcomes 7.9 I monitor and interpret antibiotic resistance patterns 7.10 Whenever possible, I incorporate information technology and systems applications in the analysis and dissemination of data using tables, graphs or charts, as appropriate 8.0 Education 8.1 I assess learning needs of my clients/customers and develop educational objectives and strategies to meet those needs 8.2 I utilize learning principles appropriate to the target audience 8.3 I am creative and effective in my educational design and delivery 8.4 I structure a learning environment that leads to openness, questioning and discussion 8.5 I prepare, present, or coordinate educational workshops, lectures, discussion or instruction on a variety of IP&C topics 8.6 I collaborate with colleagues on the development and delivery of educational programs and/or tools that relate to IP&C 8.7 I evaluate my educational programs and learner outcomes Audit Toolkit Version 2, September 2009 CHICA-Canada Page 8

9 Developing Not Applicable SELF- AUDIT TOOL for Element 8.8 I analyse evaluations and adjust educational programs accordingly 8.9 I instruct patients, families and other visitors about methods to prevent and control infections 9.0 Consultation and Communication I communicate effectively with others: 9.1 verbal skills 9.2 written skills 9.3 electronic communication skills 9.4 I provide constructive feedback to others 9.5 I work well in a group, I am a good team player 9.6 I motivate others to work towards common goals 9.7 I mentor other ICPs 9.8 I maintain access to current information on IP&C 9.9 I support clients/patients/residents, staff and administration on IP&C issues 9.10 I provide input into patient safety and health care quality initiatives related to IP&C to stakeholders 9.11 I collaborate with Risk Management/Quality Management in the identification and review of adverse and sentinel events related to IP&C 9.12 I can investigate an incident and see it through to its resolution 9.13 I can perform a root-cause analysis of an incident 9.14 I evaluate accreditation/regulatory issues related to IP&C and facilitate compliance 9.15 I collaborate with community health organizations such as Public Health in planning community responses to biological agents (e.g., influenza) 10.0 Occupational Health 10.1 I collaborate with Occupational Health and Safety (OH&S)/ Employee Health to identify and report staff health risks 10.2 I review and/or develop screening and immunization programs 10.3 I collaborate with OH&S when required following staff exposures to infectious diseases Audit Toolkit Version 2, September 2009 CHICA-Canada Page 9

10 Developing Not Applicable SELF- AUDIT TOOL for Element 10.4 I provide counselling, follow-up and work restriction recommendations related to communicable diseases or following exposures 10.5 I assess the risk of occupational exposure to infectious diseases (e.g., tuberculosis, bloodborne pathogens) 11.0 Program Administration and Evaluation 11.1 I develop an IP&C program plan with mission and vision statement, goals, measurable objectives and action plans that are based on the needs of the health care setting 11.2 I evaluate the effectiveness of the IP&C program goals and objectives annually 11.3 I develop and implement IP&C policies and procedures based on currently accepted best practices, standards and research 11.4 I ensure that IP&C policies are disseminated to appropriate groups or individuals 11.5 I provide knowledge on the function, role and value of the IP&C program 11.6 I determine resource needs to accomplish the IP&C program goals and objectives (e.g., personnel, equipment) 11.7 I communicate IP&C program resource needs to administration 12.0 Fiscal Responsibility 12.1 I practice fiscal responsibility in the management of the IP&C program I consider financial implications as well as safety and clinical outcomes when: 12.2 making recommendations for change 12.3 evaluating technology and products 12.4 developing policies and procedures 12.5 I incorporate fiscal assessments into reports as appropriate 13.0 Performance Improvement 13.1 I identify opportunities for improvement based on indicators, observations and other findings 13.2 I act as an agent of change and participate in the change process 13.3 I coordinate the health care setting s IP&C improvement activities Audit Toolkit Version 2, September 2009 CHICA-Canada Page 10

11 Developing Not Applicable SELF- AUDIT TOOL for Element 13.4 I participate in the health care setting s multidisciplinary improvement strategies 13.5 I contribute epidemiologic skills to improvement processes 14.0 Research 14.1 I critically evaluate research literature relevant IP&C and practice issues 14.2 I am aware of current research findings and related literature relevant to my area of expertise 14.3 I understand how to change practice based upon the results of research 14.4 I incorporate and disseminate research findings into practice, education and/or consultation 14.5 I organize and share findings from surveillance activities and/or outbreak investigations 14.6 I participate in IP&C-related research independently or collaboratively 14.7 I incorporate cost analysis into IP&C research when possible 14.8 I publish or present research findings to assist in advancing the field of IP&C Audit Toolkit Version 2, September 2009 CHICA-Canada Page 11

12 Appendix A: Audit Tool Follow-up Worksheet Element # Section 1: Items Marked No on audit tool Element # Sections 2 14: Items Marked Developing on audit tool NOTE: If there are more than 20 items, choose the most important Audit Toolkit Version 2, September 2009 CHICA-Canada Page 12

13 Element # Sections 2 14: Items Marked on audit tool NOTE: If there are more than 25 items, choose the most important Date written: Date reviewed with my supervisor: Audit Toolkit Version 2, September 2009 CHICA-Canada Page 13

14 Appendix B: Learning Plan Worksheet The following sample learning plan worksheet may be used to summarize the results of the audit. Using this report, you can clearly outline the area(s) of concern, action required, risk level for action, who is responsible and timelines for completion. AUDIT ELEMENT # LEARNING GOAL (Project of interest) LEARNING OBJECTIVES (What am I going to learn?) SUCCESS INDICATORS (How will I know I have learned it?) RESOURCES / LEARNING STRATEGY TARGET DATE FOR COMPLETION DATE COMPLETED Audit Toolkit Version 2, September 2009 CHICA-Canada Page 14

15 Bibliography: 1. Friedman C, Curchoe R, Foster M, Hirji Z, Krystofiak S, Lark R, et al. APIC/CHICA-Canada Infection Prevention, Control and Epidemiology: Professional and Practice Standards. Association for Professionals in Infection Control and Epidemiology, Inc, and the Community and Hospital Infection Control Association-Canada [cited November 13, 2009]; available at: 2. Association for Professionals in Infection Control and Epidemiology, Inc. APIC Code of Ethics. Am J Infect Control 1999;27(1): Friedman C, Barnette M, Buck AS, Ham R, Harris JA, Hoffman P, et al. Requirements for infrastructure and essential activities of infection control and epidemiology in out-ofhospital settings: a consensus panel report. Association for Professionals in Infection Control and Epidemiology and Society for Healthcare Epidemiology of America. Infect Control Hosp Epidemiol 1999;20(10): College of Nurses of Ontario. Professional Standards [cited November 13, 2009]. Available from: 5. Boyer L. Infection Control Professional Self-Assessment Tool. Unpublished, Dreyfus SE, Dreyfus HL. A five-stage model of the mental activities involved in directed skill acquisition. Unpublished report supported by the Air Force Office of Scientific Research (AFSC), USAF, University of California at Berkeley, February Benner P. From novice to expert - Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley Publishing Benner P. Using the Dreyfus Model of Skill Acquisition to Describe and interpret Skill Acquisition and Clinical Judgment in Nursing Practice and Education. Bulletin of Science, Technology & Society 2004;24(3): Certification Board of Infection Control and Epidemiology. A Practice Analysis of the Infection Preventionist:[Applied Measurement Professionals, Inc.]; [cited July 2, 2010]; Available from: Infection Control Nurses Association. Core Competencies for Practitioners in Infection Prevention and Control; [cited July 10, 2010]; Available from: Moralejo D. Education Member + Source Guide 2010/2011. Community and Hospital Infection Control Association Canada. DISCLAIMER: These audit tools are based on infection prevention and control best practices current at the time of publication. The individual elements provided in these tools are not intended to take the place of either the written law or regulations. Audit Toolkit Version 2, September 2009 CHICA-Canada Page 15