Quality Dimensions in Hospital Infection Control
Author(s): Shakti K Gupta*, Sunil Kant**
Vol. 14, No. 1 (2002-01 - 2002-06)
In a survey conducted in UK in the 1980's, the cost of post operative
sepsis alone was 5 million $ per year2. As is evident from Fig 1 {unavailable}a
well coordinated HAI control programme will be beneficial to the
patient as well as the hospital staff.
Quality and HAI-A Means End Relationship
Quality
means conformance of specification/standards3. To achieve an
effective HAI control programme it is essential that a continuous
monitoring is done to establish standards, achieve these and
reestablish enhanced standards. All components of quality may be
applied funtionally and operationally to attain effective efficiency in
HAI programmes. These include quality control which comprises
qualitative measurement of adequacy and acceptance of performance,
quality assurance which is the application of a series of quality
control steps at multiple stages of a procedure to verify that all
aspects of the procedure are of acceptable quality, continuous quality
improvement in which quality is more than an absence of adverse events,
it is a continues quality improvement process always striving for and
seeking new ways of improving processes. A Plan-Do-Check-Act(PDCA) as
applicable to HAI is depicted in fig 2.
FIG 2. PDCA CYCLE
Almost
150 years ago in 1847, Ignac F Semmelweis, then young assistant to
Johann Klein, Professor of Obstetrics at University of Vienna, through
series of clinical observations, identified medical practices within
hospitals as a major source and mode of spread of infections and
demonstrated that with modification of such practices, control could be
accomplished. His observations remain sufficiently cogent today5.
Application
of PDCA cycle and the JCAHO model will greatly help in reducing the
incidence of HAI. JCAHO also has an online software programme Need
Assessor' for assessment for quality evaluation and implementation.
This may be gainfully employed by healthcare institutions.
Indicators - Sua Quo-Non for Quality Assurance
An
indicator is a valid and reliable quantitative process or outcome
measure related to dimensions of performance such as effectiveness and
appropriateness.
Types of Indicators
Sentinel event indicators.
This is a performance measure that identifies an individual event that
triggers further analysis and investigations. It usually occurs in
frequently and is undesirable in nature e.g. tenfold increase in
mortality in neonatology nursery.
Rate based indicators.
This expresses proportion of number of occurrences to the entire group
within which the occurrence could take place e.g. incidence of post
operative incision sepsis.
Continuous variable indicators. This measures performance along a continuous scale e.g. zero incidence of post op sepsis during six months.
Quality Indicators.
It has been aptly said
"quality is not a number rather it is a function of positive
perceptions". Quality is never an accident, it is always the result of
good intentions, sincere efforts, intelligent direction and skilful execution. All
dimensions of quality viz accessibility, appropriateness, continuity,
effectiveness and efficiency must receive due weight. The following must be taken into consideration.
The
U.S. Joint Commission Accreditation of Health Care Organization (JCAHO)
Quality Assurance Model4 as applicable to HAI is depicted in Fig. 3.
Fig 3. Quality Assurance Model (JCAHO)
- The
health care system in India is diversified, divergent with a drastic
difference in standards for urban and rural areas. Thus quality
indicators must appropriately be enunciated and implemented.
- Accreditation
is the catalyst for quality care. Accreditation and assessment of
health care institutions have been recognized as the must be relevant,
understandable, measurable and achievable. Accreditation aids in
establishing standards, measuring performance and identifying areas for
improvement.
One
of the major elements in the service area is the concept of
consideration. Usually cost and price are important parameters. These
are now been gradually replaced by he elements of consideration.
Consideration is price plus loss of dignity, waiting time, anxiety etc.
If a person coming to a health care institution pays nothing but has a
high risk of acquiring HAI, he would certainly refuse of utilize the
facility. Reducing consideration is thus an important quality indicator
and an essential parameter to achieve continuous quality improvement
(CQI).
Normative Weighted Criteria
A
patient or his relatives, wishing to utilize a healthcare institutions
should have a known predetermined quality standard available for
guidance. This will also aid hospital administrators and policy makers
at various levels to direct activities for improvement of facilities.
The
following parameters related to HAI have been weighted as their related
importance. The parameters have been clubbed as per their structure,
process or outcome affiliation. The mentioned weighted credits are the
maximum that may be granted to a particular parameter.
Structure Criteria
Has
a well enunciated hospital Infection control committee incorporating a
hospital administrator, microbiologist, clinician and a nursing
administrator.
5
Has
a functional hospital infection team incorporating microbiologist,
nursing staff, housekeeping staff and an epidemiologist.
5
There exists specific job description for each personnel of above committee/team.
5
Physical
facilities are conducive for prevention of hospital infection such as
ward design bed spacing, flooring, isolation rooms, drainage etc.
5
House
keeping services and biomedical waste management are appropriately
incorporated in thehospital infection control programme.
5
Procedures and Policies
Has
well enunciated principles of hospital infection control such as to
eliminate sources of infection, and routes of spread, surveillance for
infection, investigations during outbreaks etc.
5
Existence of comprehensive standing operative procedures (SOPs) for hospital infection control programme including
disinfection and sterilization of equipment, universal precautions,
protective vaccinations vis hepatitis, tetanus and gas gangrene, use of
disposables, housekeeping disinfectants, handing of specimens barrier
and reverse barrier nursing.
5
Has a functional antibiotic policy.
5
Has
an interactive inter departmental coordination in reference to hospital
infection control programme including services such as housekeeping,
laundry, CSSD and dietary.
5
Process Criteria
Scientific
data collection and analysis related to hospital infection control
programme during surveillance and investigation for HAI. Comprehensive
documentation exists.
5
Scientific
sample collection and laboratory investigation Molecular methods are
being utilized in laboratory investigations for HAI.
5
Internal and external audit for laboratory investigations.
5
Awareness levels amongst various staff personnel regarding HAI.
5
Training and reorientation programmes being conducted related to HAI.
5
Cost evaluation analysis for antibiotic usage, HAI etc.
5
Activities aimed for achievement of CQI.
5
Outcome
Hospital infection rate viz-a-viz incidence at local/national/international levels.
10
Satisfactory internal and external laboratory audit.
5
Staff and patient satisfaction.
5
Total Credit Points
100
The grading may be done as follows
Credit Point
Gradings
These are suggested credit parameters and gradings.
These may be modified appropriately
for various health care Institutions
80-100
A++
Outstanding
70-80
A+
V. Good
60-70
A
Good
50-60
B
Average
Below
C
Below average
Need of the Hour-Certification of Services and Newer Techniques
India
does not have an organization like JCAHO of USA. Till a comprehensive
accreditation system for health care services is organized, third
party, quality system certification by such agencies as BIS and STQC
must be undertaken. ISO 9000 series certification for healthcare
institutions will be helpful in evaluating and improving methods,
policies and procedures related to hospital infection control.
An
important feature of an epidemiologic evaluation is the determination
of clonality of the suspected pathogen regardless of the mode of
transmission. The rapid advancement of genotypic typing techniques in
the last few years has helped in understanding the epidemiology of the
various pathogens especially frequently encountered in the
hospital-acquired infection. Molecular methods such plasmid profile
analysis (PPA), restriction endonulease analysis (REA), pulse field gel
electrophesis (PFGE) are becoming more useful when combined with
epidemiologic analysis of infectious disease outbreaks6. With
these tools hospital epidemiologist with laboratory help can rapidly
diagnose an otherwise difficult to detect pathogen and thus initiate
specific infection control measures promptly7. If these techniques
are made available to the hospitals at affordable cost, the agencies
involved in prevention and control of hospital acquired infection can
develop better prevention strategies5.
Software
products, journals and organizations are available which deal
exclusively and extensively with hospital infections. Apart from the
Need Assessor' of JCAHO some the other related products/journals/
organization are
- American journal of Infection Control available on internet at site http://www.md.ucl.ac.be/didac/hosp/infon.htm.
- CDC, Atlanta guidelines available on net site http:/www.cdc.gov/ncidod/hip/.
- AICE
' an software product is being utilized for Infection Control Quality
Improvement of healthcare facilities. AICE! Millennium and
Century Long Term Care' software monitor and analyze hospital
infections. The software may also be utilized to investigate infection
outbreaks, analyze risk factors and benchmark data. Q Trendz' is an
add on to AICE programmes which plots control charts as surveillance
data using predetermined indicators8.
References
- Gupta
S, Kant S, Quality and Hospital Housekeeping: Emerging Issues and
Future Dimensions, JK Science Vol 3, No.2. 2001; 94-97.
- Precis on Hospital Administration, Armed Forces; 1988.
- Bureau of Indian Standards Quality Management and Quality and Quality System Elements: Guidelines for Services: 14004 (Part-2), 1992.
- Bishop C: Health Care TQM: An overview: Asian Hospital, 1994: 68-69.
- Chander Y, Rai R, Hospital Acquired Infection, Medical Journal Armed Forces India 1998, 1998, 54: 174-81.
- Lupski JR. Molecular Epidemiology and its Clinical Applications. JAMA 1993; 270:1363-4.
- Templeton NS. The polymerase chain reaction: history, methods and applications. In: The Diagnostic Molecular Pathology. New York: Raven Press, 1992:58-72.
- http://www.icpa.net/
* Add. Prof. Deptt. of Hospital Administration, AIIMS, New Delhi.
** Office of DGMS (Army) Ministry of Defence Govt. of India
In a survey conducted in UK in the 1980's, the cost of post operative sepsis alone was 5 million $ per year2. As is evident from Fig 1 {unavailable}a well coordinated HAI control programme will be beneficial to the patient as well as the hospital staff.
Quality and HAI-A Means End Relationship
Quality means conformance of specification/standards3. To achieve an effective HAI control programme it is essential that a continuous monitoring is done to establish standards, achieve these and reestablish enhanced standards. All components of quality may be applied funtionally and operationally to attain effective efficiency in HAI programmes. These include quality control which comprises qualitative measurement of adequacy and acceptance of performance, quality assurance which is the application of a series of quality control steps at multiple stages of a procedure to verify that all aspects of the procedure are of acceptable quality, continuous quality improvement in which quality is more than an absence of adverse events, it is a continues quality improvement process always striving for and seeking new ways of improving processes. A Plan-Do-Check-Act(PDCA) as applicable to HAI is depicted in fig 2.
FIG 2. PDCA CYCLE
Almost 150 years ago in 1847, Ignac F Semmelweis, then young assistant to Johann Klein, Professor of Obstetrics at University of Vienna, through series of clinical observations, identified medical practices within hospitals as a major source and mode of spread of infections and demonstrated that with modification of such practices, control could be accomplished. His observations remain sufficiently cogent today5.
Application of PDCA cycle and the JCAHO model will greatly help in reducing the incidence of HAI. JCAHO also has an online software programme Need Assessor' for assessment for quality evaluation and implementation. This may be gainfully employed by healthcare institutions.
Indicators - Sua Quo-Non for Quality Assurance
An indicator is a valid and reliable quantitative process or outcome measure related to dimensions of performance such as effectiveness and appropriateness.
Types of Indicators
Sentinel event indicators. This is a performance measure that identifies an individual event that triggers further analysis and investigations. It usually occurs in frequently and is undesirable in nature e.g. tenfold increase in mortality in neonatology nursery.
Rate based indicators. This expresses proportion of number of occurrences to the entire group within which the occurrence could take place e.g. incidence of post operative incision sepsis.
Continuous variable indicators. This measures performance along a continuous scale e.g. zero incidence of post op sepsis during six months.
Quality Indicators.
It has been aptly said "quality is not a number rather it is a function of positive perceptions". Quality is never an accident, it is always the result of good intentions, sincere efforts, intelligent direction and skilful execution. All dimensions of quality viz accessibility, appropriateness, continuity, effectiveness and efficiency must receive due weight. The following must be taken into consideration.
The U.S. Joint Commission Accreditation of Health Care Organization (JCAHO) Quality Assurance Model4 as applicable to HAI is depicted in Fig. 3.
Fig 3. Quality Assurance Model (JCAHO)
- The health care system in India is diversified, divergent with a drastic difference in standards for urban and rural areas. Thus quality indicators must appropriately be enunciated and implemented.
- Accreditation is the catalyst for quality care. Accreditation and assessment of health care institutions have been recognized as the must be relevant, understandable, measurable and achievable. Accreditation aids in establishing standards, measuring performance and identifying areas for improvement.
One of the major elements in the service area is the concept of consideration. Usually cost and price are important parameters. These are now been gradually replaced by he elements of consideration. Consideration is price plus loss of dignity, waiting time, anxiety etc. If a person coming to a health care institution pays nothing but has a high risk of acquiring HAI, he would certainly refuse of utilize the facility. Reducing consideration is thus an important quality indicator and an essential parameter to achieve continuous quality improvement (CQI).
Normative Weighted Criteria
A patient or his relatives, wishing to utilize a healthcare institutions should have a known predetermined quality standard available for guidance. This will also aid hospital administrators and policy makers at various levels to direct activities for improvement of facilities.
The following parameters related to HAI have been weighted as their related importance. The parameters have been clubbed as per their structure, process or outcome affiliation. The mentioned weighted credits are the maximum that may be granted to a particular parameter.
| Structure Criteria | |
| Has a well enunciated hospital Infection control committee incorporating a hospital administrator, microbiologist, clinician and a nursing administrator. | 5 |
| Has a functional hospital infection team incorporating microbiologist, nursing staff, housekeeping staff and an epidemiologist. | 5 |
| There exists specific job description for each personnel of above committee/team. | 5 |
| Physical facilities are conducive for prevention of hospital infection such as ward design bed spacing, flooring, isolation rooms, drainage etc. | 5 |
| House keeping services and biomedical waste management are appropriately incorporated in thehospital infection control programme. | 5 |
| Procedures and Policies | |
| Has well enunciated principles of hospital infection control such as to eliminate sources of infection, and routes of spread, surveillance for infection, investigations during outbreaks etc. | 5 |
| Existence of comprehensive standing operative procedures (SOPs) for hospital infection control programme including disinfection and sterilization of equipment, universal precautions, protective vaccinations vis hepatitis, tetanus and gas gangrene, use of disposables, housekeeping disinfectants, handing of specimens barrier and reverse barrier nursing. | 5 |
| Has a functional antibiotic policy. | 5 |
| Has an interactive inter departmental coordination in reference to hospital infection control programme including services such as housekeeping, laundry, CSSD and dietary. | 5 |
| Process Criteria | |
| Scientific data collection and analysis related to hospital infection control programme during surveillance and investigation for HAI. Comprehensive documentation exists. | 5 |
| Scientific sample collection and laboratory investigation Molecular methods are being utilized in laboratory investigations for HAI. | 5 |
| Internal and external audit for laboratory investigations. | 5 |
| Awareness levels amongst various staff personnel regarding HAI. | 5 |
| Training and reorientation programmes being conducted related to HAI. | 5 |
| Cost evaluation analysis for antibiotic usage, HAI etc. | 5 |
| Activities aimed for achievement of CQI. | 5 |
| Outcome | |
| Hospital infection rate viz-a-viz incidence at local/national/international levels. | 10 |
| Satisfactory internal and external laboratory audit. | 5 |
| Staff and patient satisfaction. | 5 |
| Total Credit Points | 100 |
The grading may be done as follows
| Credit Point | Gradings | These are suggested credit parameters and gradings. These may be modified appropriately for various health care Institutions |
|
| 80-100 | A++ | Outstanding | |
| 70-80 | A+ | V. Good | |
| 60-70 | A | Good | |
| 50-60 | B | Average | |
| Below | C | Below average |
Need of the Hour-Certification of Services and Newer Techniques
India does not have an organization like JCAHO of USA. Till a comprehensive accreditation system for health care services is organized, third party, quality system certification by such agencies as BIS and STQC must be undertaken. ISO 9000 series certification for healthcare institutions will be helpful in evaluating and improving methods, policies and procedures related to hospital infection control.
An important feature of an epidemiologic evaluation is the determination of clonality of the suspected pathogen regardless of the mode of transmission. The rapid advancement of genotypic typing techniques in the last few years has helped in understanding the epidemiology of the various pathogens especially frequently encountered in the hospital-acquired infection. Molecular methods such plasmid profile analysis (PPA), restriction endonulease analysis (REA), pulse field gel electrophesis (PFGE) are becoming more useful when combined with epidemiologic analysis of infectious disease outbreaks6. With these tools hospital epidemiologist with laboratory help can rapidly diagnose an otherwise difficult to detect pathogen and thus initiate specific infection control measures promptly7. If these techniques are made available to the hospitals at affordable cost, the agencies involved in prevention and control of hospital acquired infection can develop better prevention strategies5.
Software products, journals and organizations are available which deal exclusively and extensively with hospital infections. Apart from the Need Assessor' of JCAHO some the other related products/journals/ organization are
- American journal of Infection Control available on internet at site http://www.md.ucl.ac.be/didac/hosp/infon.htm.
- CDC, Atlanta guidelines available on net site http:/www.cdc.gov/ncidod/hip/.
- AICE ' an software product is being utilized for Infection Control Quality Improvement of healthcare facilities. AICE! Millennium and Century Long Term Care' software monitor and analyze hospital infections. The software may also be utilized to investigate infection outbreaks, analyze risk factors and benchmark data. Q Trendz' is an add on to AICE programmes which plots control charts as surveillance data using predetermined indicators8.
References
- Gupta S, Kant S, Quality and Hospital Housekeeping: Emerging Issues and Future Dimensions, JK Science Vol 3, No.2. 2001; 94-97.
- Precis on Hospital Administration, Armed Forces; 1988.
- Bureau of Indian Standards Quality Management and Quality and Quality System Elements: Guidelines for Services: 14004 (Part-2), 1992.
- Bishop C: Health Care TQM: An overview: Asian Hospital, 1994: 68-69.
- Chander Y, Rai R, Hospital Acquired Infection, Medical Journal Armed Forces India 1998, 1998, 54: 174-81.
- Lupski JR. Molecular Epidemiology and its Clinical Applications. JAMA 1993; 270:1363-4.
- Templeton NS. The polymerase chain reaction: history, methods and applications. In: The Diagnostic Molecular Pathology. New York: Raven Press, 1992:58-72.
- http://www.icpa.net/
* Add. Prof. Deptt. of Hospital Administration, AIIMS, New Delhi.
** Office of DGMS (Army) Ministry of Defence Govt. of India