SAMPLE
INFECTION PREVENTION AND CLINICAL EPIDEMIOLOGY
ANNUAL RISK ASSESSMENT/STRATEGIC WORK PLAN for ASC Name and Year
Infection
Control/Epidemiology Risk
Characteristics
Hand Hygiene (HH) Practices
Obs Correct HH < 90%
Obs Correct HH 90-99%
Obs Correct HH 100%
Surgical Site Infections (SSI)
Ortho, ENT, Plastics,
Vasectomies etc. and any
Focused Studies.
Risk Category
Determination
X High
X High
Goal
Objective
Indicators
Data Analysis
(Refer to attachment 1 for in
depth rates)
Plan of Action
Enforcement and
enhancement of hand
hygiene practices are
implemented within
the organization.
ASC-wide hand hygiene program is
implemented that complies with
CDC guidelines and TJC NPSG 7.
90-100%
Coordinate/consult/educate all areas
of ASC on Infection Prevention
Process and Outcome Measures.
1.
Enforce education and compliance with
results from the monthly hand hygiene
observations and all other rounds
described for hand hygiene.
Patient speak up campaign brochure.
Governing body Quality
Committee/Board receive reports of
compliance monthly /quarterly
Hand Hygiene compliance reported out
thru the ICC/Quality committee.
Reinforce good behavior with incentives.
Strategic goal for the organization
Target-84%, Maximum 86%
Decrease SSI rates to
target X.
Full compliance with
IHI bundle CDC
recommendations for
SSI prevention and
SCIP measures.
Analyze data collected on SSIs,
including numerators and
denominators.
Generate baseline rates and
benchmark against historical data
and NHSN.
Make recommendations for
improvement using the IHI SSI
prevention bundle and other
infection prevention strategies.
Put data here:
SSI rates for selected procedures
Investigate identified
clusters/focused studies.
Coordinate/consult/educate all areas
of ASC on Infection Prevention
Process and Outcome Measures.
1/4/2012
2.
Daily/weekly focused
random hand hygiene
practice observations per
month are being captured
alcohol gel usage reports.
To investigate potential causes of rates
occurring above the CDC 50th percentile
in either of these 2 procedures, IC
continues to perform retrospective chart
reviews on those patients with SSI looking
for breaches in those processes associated
with the SSI bundle that include:
appropriate initiation and discontinuation
of antibiotics, clipping versus shaving for
hair removal and perioperative glucose
control.
The systematic collection and analysis of
data noting the compliance rate to all the
SSI bundle measures should ideally be
done for all surgery types, so that a
comparison can be made of the
compliance rates between those patients
with SSI and patients without SSI for the
same type of surgical procedure.
Implementation of the SSI bundle
Page 1 of 8
SAMPLE
INFECTION PREVENTION AND CLINICAL EPIDEMIOLOGY
ANNUAL RISK ASSESSMENT/STRATEGIC WORK PLAN for ASC Name and Year
Infection
Control/Epidemiology Risk
Characteristics
Risk Category
Determination
Goal
Objective
Indicators
Data Analysis
(Refer to attachment 1 for in
depth rates)
Plan of Action
continues in collaboration SCIP and
NSQIP.
Working with surgeons to have
accurate Wound Class and ASA
scores assigned to patints by
surgeon.
TJC – Continued Readiness.
X High
Constant State of
Readiness.
Protect patients, employees and
physicians by promoting best
Infection Prevention Practices
Coordinate/consult/educate all areas
of ASC on Infection Prevention
Process and Outcome Measures.
Compliance to NPSG #7
Prevention of Health care
associated Infections
Control TJC and DHS
standards.
o
o
o
o
o
Cluster/Outbreaks
Emerging Infectious Disesases
Community:
MRSA, MDRO’s, Pertussis,
varicella, Norovirus,,
Influenza, hepatitis A&B,
pandemic flu and any new
emerging infectious disease
X High
X Medium
Investigate the cause of an
unexpected increase in community
and/or health care associated
infections.
Recommend interventions that
result in prevention or a sustained
decrease in the infection rate.
Coordinate/consult/educate/rounds
all areas of ASC on Infection
Prevention Process and Outcome
Measures.
Data here:
MRSA rates
Facility: None
Implementation of
infection prevention
strategies in
relationship to the
mechanisms of
transmission, care,
treatment, and the
pathogens that place
communities at risk.
Reduce morbidity and
mortality due to these
pathogens.
Implementation of
respiratory etiquette
/hand hygiene
programs.
Compliance with standard &
transmission based precautions, hand
hygiene and appropriate PPE use.
Compliance with environmental cleaning
practices and patient equipment cleaning
and disinfection
Screening for exposures and immunity
per policy.
Referral for assessment, testing,
immunizations up to date on all staff and
is achieved at 100% for individuals who
may put population at risk and who have
been occupationally exposed to
infectious agents.
1/4/2012
Surveillance Rounds
EOC rounds
Construction Rounds
IC rounds
Education to Leaders, physicians
and Staff
Compliance with patient hygiene, oral
care and bathing when clinically
appropriate.
Page 2 of 8
SAMPLE
INFECTION PREVENTION AND CLINICAL EPIDEMIOLOGY
ANNUAL RISK ASSESSMENT/STRATEGIC WORK PLAN for ASC Name and Year
Infection
Control/Epidemiology Risk
Characteristics
Risk Category
Determination
Goal
Objective
Indicators
Data Analysis
(Refer to attachment 1 for in
depth rates)
Influenza/Pandemic Influenza
Bioterrorism and Emergency
Preparedness.
X High
Prevent health care
associated
transmission and
outbreaks.
Continually update and monitor a
comprehensive flu plan in
coordination with local, state and
federal authorities. Monitor trends
and implement IC practices known
to minimize the spread of influenza.
Train in the rapid isolation or
cohorting of infectious patients.
Immunize staff with direct patient
care and susceptible patients.
Educate and inform staff &
physicians as new information
arises.
Coordinate/consult/educate all areas
of ASC on Infection Prevention
Process and Outcome Measures.
Compliance with offering all
employees, LIP’s, volunteers,
etc. Flu vaccination.
Use of proper respiratory
etiquette and hand hygiene.
Mask fit testing as needed.
Adherence and compliance to
the Aerosol Transmissible
Disease (ATD) Standards/TB
Control Plan
1/4/2012
Plan of Action
Offer flu vaccine to all ASC employees,
LIP’s etc.
Healthy incentive for HCW’s tied to
compliance with vaccination status or
declination.
Page 3 of 8
SAMPLE
INFECTION PREVENTION AND CLINICAL EPIDEMIOLOGY
ANNUAL RISK ASSESSMENT/STRATEGIC WORK PLAN for ASC Name and Year
Infection
Control/Epidemiology Risk
Characteristics
Facility Construction
Current or planned
construction/renovation/demoli
tion activities.

Dust Control and
Containment
Risk Category
Determination
X High
Goal
Objective
Indicators
Data Analysis
(Refer to attachment 1 for in
depth rates)
Plan of Action
Reduce HAI
associated with
construction activities.
Maintain and monitor an aggressive
surveillance, dust control &
containment, humidity and mold
abatement program.
Continuously evaluate and educate
for IC compliance by
subcontractors, project managers,
engineers, inspectors of record.
Daily rounds in construction areas.
Review of all construction projects
and sign off on major projects for
dust control and containment. IC
involved in any unanticipated
construction projects in patient care
areas from preconstruction through
all the stages of construction. IC
rounds on the project sites to
monitor compliance with
containment. ICRA signed and
posted at site.
100% compliance with ICRA.
No trends in diseases known to
be associated with
construction.
An infection control risk assessment and
dust control and containment policy and
procedure is followed for all construction
projects.
Do rounds daily on all major
construction projects and regularly
evaluates the scope of level 1 and 2 in
the event that the acuity is higher.
IC rounds weekly and as needed. IC has
the oversight for all projects and asks for
action plans when there is poor
compliance on major construction
projects.
1/4/2012
All contractors go thru Dust control and
containment P&P before starting a
project.
.
Page 4 of 8
SAMPLE
INFECTION PREVENTION AND CLINICAL EPIDEMIOLOGY
ANNUAL RISK ASSESSMENT/STRATEGIC WORK PLAN for ASC Name and Year
Infection
Control/Epidemiology Risk
Characteristics
Risk Category
Determination
Goal
Objective
Indicators
Data Analysis
(Refer to attachment 1 for in
depth rates)
Plan of Action
Presence of Multi Drug
Resistant Organisms (MDRO)
Patient population > 20%
resistance :
MRSA, VRE, C. difficile,
ESBL
X High
Prevent transmission
of MDRO.
Undertake actions to evaluate
incidence of health care associated
transmission.
Implement strategies to reduce
health care associated transmission.
Recommend interventions based on
findings and assessment of risk.
Coordinate/consult/educate all areas
of ASC on Infection Prevention
Process and Outcome Measures.
Attachment data MRSA rates
Monitor compliance with standard
precautions, hand hygiene and
environmental cleaning.
.
Enhanced environmental cleaning
protocals with housekeeping and
Nursing.
1/4/2012
Page 5 of 8
SAMPLE
INFECTION PREVENTION AND CLINICAL EPIDEMIOLOGY
ANNUAL RISK ASSESSMENT/STRATEGIC WORK PLAN for ASC Name and Year
Infection
Control/Epidemiology Risk
Characteristics
Risk Category
Determination
Goal
Objective
Indicators
Data Analysis
(Refer to attachment 1 for in
depth rates)
Plan of Action
Screen at pre-op outpatient visit all
elective orthopedic surgical patients
Nasal swab (anterior nares) by RN sent
for “MRSA screen”
Based on Culture Results (only if MRSA
and CHG bathing pre op and post op.
Prophy for MRSA + Vancomycin.
Cefazolin for MRSA -. Environmental
cleaning per protocal
Tuberculosis
Pulmonary TB cases in past 6
months

X High
Prevent transmission
of pulmonary TB in
community and
healthcare workers.
X Medium
X Low
X Medium
1/4/2012
Review and revise Aerosol
Transmissible Disease (ATD)
Standards/ TB exposure and control
plan annually and as needed.
Identify all suspect and actual cases
of pulmonary TB and initiate
airborne precautions upon entry to
ASC.
Continued education to physicians
and staff on preventative measures
(fit testing and annual skin testing
and use of appropriate PPE).
TB screening Compliance in X
Fit Testing Compliance in :
Overall compliance is X
Active Management of pulmonary
tuberculosis remains a significant activity
over time. The early recognition of
tuberculosis and placement in
appropriate airborne precautions
minimizes the risk of transmission to
staff and other patients.
Page 6 of 8
SAMPLE
INFECTION PREVENTION AND CLINICAL EPIDEMIOLOGY
ANNUAL RISK ASSESSMENT/STRATEGIC WORK PLAN for ASC Name and Year
Infection
Control/Epidemiology Risk
Characteristics
Risk Category
Determination
Goal
Objective
1/4/2012
Indicators
Data Analysis
(Refer to attachment 1 for in
depth rates)
Plan of Action
Page 7 of 8
SAMPLE
INFECTION PREVENTION AND CLINICAL EPIDEMIOLOGY
ANNUAL RISK ASSESSMENT/STRATEGIC WORK PLAN for ASC Name and Year
Infection
Control/Epidemiology Risk
Characteristics
Risk Category
Determination
Goal
Objective
Indicators
Data Analysis
(Refer to attachment 1 for in
depth rates)
Plan of Action
Infection Control Surveillance
in the:

Ambulatory Surgery
Services
X High
Prevent transmission
of Infectious Diseases
and exposure to
opportunistic
pathogens.
Monitor rates of targeted diseases
such as Tuberculosis, MRSA, hand
hygiene compliance,
Undertake actions to evaluate
incidence of health care associated
transmission.
Implement strategies to reduce
health care associated transmission.
See Attachment Data.
Targeted surveillance of SSI,
hand hygiene,
Recommend interventions based on
findings and assessment of risk.
Coordinate/consult/educate all areas of
ASC on Infection Prevention Process
and Outcome Measures.
1/4/2012
Page 8 of 8