Respect my authority

There was an article recently that sort of triggered me, and I wanted to talk about it a bit.  It’s about being the only voice in Infection Prevention, and sometimes being frustratingly powerless to make necessary changes for patient safety.  If you work in a large organization, you might not know what I’m talking about.  But I’ve spent most of my time in small places where I am the only voice. It doesn’t happen always, but often enough that it has made me wonder why I do this job.

I have worked in a few different arrangements:

• A mid-sized hospital, with another ICP, and 2 ID physicians who: saw patients, chaired the IC committee, provided consults to colleagues, took call overnight, and were involved in antibiotic usage.
• A small hospital, where I was the only IP.  One ID physician who: covered many facilities on consult and had an outpatient practice, was supportive, but very busy, came to IC committee, but I did all the work.
• A small hospital where I was the only IP. All calls were mine. The ID physician was on consult to the IC program, did not see patients at the facility, employed elsewhere, engaged at quarterly IC committee, but mostly unavailable otherwise.
• A very small hospital where I was a consultant ICP for just a few hours a week.  No ID physician.  All calls were mine. I ran committee, and an MD was present and signed off.

When there is an issue in infection control, and there is no readily available physician or other staff, it is up to me to present the issue and my suggestion for ameliorating it.  I am confident in my knowledge and skills, but frequently this is not enough.  I simply have no authority to implement significant changes without support from administration.

When a CRE patient presents from an outside facility, I gather the key players, and explain current CDC guidance for patient care.  I print fact sheets for patients and staff.  I make myself available on the unit for questions and support. But I cannot implement the recommended staffing changes.  I am told that it isn’t possible for the nurse to have only one patient.  Maybe it’s a budget issue, or a planning issue, or they don’t completely understand the implications of CRE spreading.  But I cannot control it.

When the OR staff reports that a surgeon doesn’t wash his hands due to a skin condition, I approach my boss.  She agrees this is serious.  She arranges a meeting with the surgeon.  He explains his issue.  I grit my teeth while she suggests other options out loud: double gloves, a dermatology consult, different soap.  I explain the standards.  She asks me to see if he has a higher rate of infections in his patients.  The numbers are too small for meaningful comparison.  She takes this as ‘no.’  She tells me we can’t take away his job. He continues to practice.

I find expired skin antiseptics in a supply closet.  I let staff know they need to be thrown away and replaced.  They tell me that then they won’t have any because the secretary does the ordering and she’s off next week.  I ask how they check for expired supplies.  Blank stares.  I find many more.  I have no boss in this small organization.  He left 6 months ago, and they haven’t found a replacement.  Next in line is the CEO.  I do not know who he is, and he likely can’t order supplies.  At the next committee meeting, it’s agreed that someone should be in charge of checking and ordering supplies.  The nurse manager says her staff don’t have time. There is literally no solution anyone can agree to, and I am stunned.

The majority of us in the US are ICPs in small facilities.  It can be very frustrating to be expected to maintain the same standards that large facilities have.  I want everything for my patients--the safest care, according to recommended practice standards.  But in all but one site I have worked in, the IC department didn’t even have its own budget.  Nothing specifically allocated to education, to supplies.  Just a salary, for someone to come in and fill that CMS required role.  And directors who look surprised when you show up holding guidelines and asking for support and action.  Perhaps they hoped I would just sit in the office and tabulate things.  Instead, I sit in the office and document things.  Because when something goes wrong, I will have evidence that I did everything I could within my power to inform those who do have the power.  And it will not be on me.

Bombs away

I stepped away for a bit.  I gave plenty of notice, trained a new person, and left my job 6 months ago.  It was a good time for me.  With a little help from Mr.MoneyMustache, I got some perspective, put things in order, and took some time for myself.  

Sometimes you’re too busy to do the job well.  The days can be long, and I was barely keeping up with new regulations and standards.  Reading that I had planned to do later just wasn’t getting done, because by the time I got home I did not want to do more work.  As a salaried employee, it’s often required, and I get that, but something was just missing for me, and I wasn’t enjoying it much anymore. In my time off, I enjoyed summer vacation with my family, went to a 3-day conference that I would never have been able to get to if I was still working, and read through a growing stack of journals and regulations from the comfort of my front porch.  And I picked up a part-time job in the microbiology lab, where I go 2 days a week, and happily punch out after 8 hours.  I needed to put my hands on something real, something that felt like patient care. I also joined the board of my local IC chapter, which I had long wanted to do. But I’ll be back to infection control soon.

I’m still on staff at my old job, just on the periphery, supporting the newbie through any crisis.  And I have a bit of a different perspective watching her work.  She can get overwhelmed by the crises.  You should know that bombs drop on Infection Control on the regular (or irregular. Or regularly irregularly).  You can’t get flustered.  This, too, shall pass.

The key is being prepared.  You need to leave mental room in your workflow and in your stress level for bombs that will drop.  (Great time mgmt piece, here..Almost all pertinent to IC). You will be plugging along, preparing docs for meetings, calculating your hand hygiene, doing new employee orientation every other Monday...and a bomb will drop on your desk.

 A kitchen worker has a positive Hepatitis A test.   Are you kidding me?  Call Employee Health, make sure he’s out and under the care of a physician.  Just get him out of the workplace and figure out the rest after.  Check your patients, is anyone sick?  Call your board of health, if they haven’t called you first, about that positive test.  Nobody is sick. Good.  When did he work last?  Find your guidelines on Hep A--state, local, or CDC.  Who needs to be vaccinated? Anyone? Can pharmacy get vaccine?  Administration wants a huddle about this.  NOW.  

This is a bomb.  It will require you to stay late, write a lot of things down, call a lot of people, wait for them to call you back, provide education, and maybe pretend that it’s totally under control.  Which it will be, in 2 or 3 days.  So hopefully, your mandated data reporting isn’t due tomorrow.  Or your report to the hospital board.  You’ve got to leave yourself a small buffer.  Do not be a procrastinator in this job, because you don’t know when the next crisis will hit.  Sometimes even a little crisis (like falsely positive Hep A tests, which happen a lot) takes a couple of days to sort out.  A major crisis (like staff drug diversion with multiple exposed and infected patients), takes weeks.  

When something super major happens, you can be assured that your state board of health will step in, or a federal authority, heaven forbid.  And you will have support, or you may even be pushed out of the way.  But small bombs are all yours.  If you’re new, or in a small or resource-weak setting, you should have a mentor, or a resource somewhere.  Maybe an ICP from a nearby hospital, someone with a little more experience under their belt, who can point you towards the right guidelines and documents.  Try to make connections at a local conference.  Just be honest, and say, “Hey, I’m all alone at our 12-bed hospital.  Do you think I could give you a call to talk through something if I get a tough situation?”  Hopefully, that person is flattered that you asked, and you get a few phone numbers to keep in your pocket.

It can definitely feel like nobody listens to me when I tell them to wash their hands or document the patient’s stools carefully.  But in a crisis situation, I’ve sat in the C-suite with everyone looking at me for what to do next.  It’s the only time I have a modicum of authority (IC is tons of responsibility, zero authority). The very first step in crisis control is to stop the offending issue immediately, and then head to your office to find your guidelines, review your policy, and make a phone call.  CDC has good resources on the steps of an outbreak investigation, and plenty of disease-specific resources for illness in healthcare settings. (And know that you are not the first person to have faced such an issue before--whether it’s mold in the OR, faulty sterilizers, hepatitis A in food service staff, or flu amongst the patients.)

No matter how new you are, you are still the most knowledgeable person in your facility regarding infection prevention and control.  Put on a confident face (and a decent shirt), and tell what you know, and what you don’t, what your next steps are, and what you need from them.  People are looking to you. And you’re going to do great.

 **Patient notification is the last step in a crisis, when necessary.  Don’t ever notify anyone of anything until you have every last piece of info, and the local health department is on board. It’s a very big deal. Do not attempt any part of patient notification alone.

Look Closely

I recently trained a brand-new ICP.  There’s so much to teach, but if you get a good candidate, it’s easy, because so much of what we do is common sense.  She sometimes came to me after doing rounds, and remarked on something that didn’t look quite right, but she wasn’t sure how to handle it. So before she had read and memorized a thousand pages of infection control reference materials and guidelines and policies, she knew when something wasn’t right.  Infection control gives you new eyes on a place you’ve worked for years.   

The next step after recognizing an issue is knowing where to find the answer.  Does your issue really violate good infection control practices and patient safety? You need to know your resources, but you don't need to memorize every one.  Google is my best friend.  Because the problem you are facing is not likely the first occurrence of said problem in the history of modern healthcare, there is information out there somewhere on it.  Often my search leads directly to one of the published guidelines, and then I don’t have to know exactly which one it is off-hand.  I find the CDC MDRO and Precautions guidelines overlap a lot, and the SHEA compendium overlaps APIC.  So if you are looking for exact wording on your issue without reading through each one, just do an internet search with as many key words as you can.

Over the years, I’ve collected (and I’m sure many ICPs have) a number of photos of things that didn’t look right.

Exhibit 1:

This is a feeding pump.  Staff let the pediatric patients decorate it with adhesive stickers to make it look it more friendly.   Does it look not-quite-right to you?  It should.  All of that adhesive attracts debris, and you can’t clean adhesive.   In fact, those stickers are debris. Feeding fluids are full of sugars, proteins, and other nutrients that are great for feeding humans and bacteria.  There should not be adhesives on patient care items. Reference: CDC Guideline for Cleaning and Disinfection

Exhibit 2:

This is drinks at the nursing station.  I count 3 from this angle. Along with a personal bag.  We use this counter to put laboratory specimens, patient charts (gross), glcuometers, etc.  It is not a clean area.  Staff should have a clean area for food and drinks in a non-clinical space, and should have a work flow that allows for breaks for their own fluid intake.  This is up to the manager to police and enforce.  I always find more drinks after-hours than during the day.  Reference: OSHA blood borne pathogen standard.

Exhibit 3:

This is an isolation gown, hanging on the doorknob, ready to be worn again…..   Does it look wrong?  If you don’t see dozens of gowns on doorknobs, then one should strike you as an aberrancy, something out of the ordinary.  Isolation gowns are worn once.  They are considered contaminated once worn, and you would not be able to put it on again without recontaminating yourself.  This is wrong. Reference: CDC Guideline for Isolation Precautions.

Exhibit 4:

I didn’t take this photo; an environmental services manager did, and brought it to me.  He said, “Can they leave the ceiling open?” No, they can’t. This is open for work being done in a patient room.  He walked by the room and the door was open, and no worker was nearby.  As the room is empty, it’s likely been cleaned.  Does the Facilities staff know they need to contain debris from the ceiling in a patient area? That a ladder and open tiles shouldn’t be unattended?  Does the nursing staff know that they can’t just push the bed back in there, as the room needs to be cleaned again?   This is the result of poor project planning: Nursing needs to know what work is being done, Facilities needs to know how to do it safely, and everyone, including EVS, needs to be sure the room is clean after.

Exhibit 5:

What’s this?  I wish it was a better pic. But this is several layers of plastic (soft) containment set up during major construction in a hospital.  Is something wrong here?  Why, yes.  I can see the glowing exit sign at the end of the hallway they are working in.  This is 2 layers of containment, both open, gently blowing in the breeze, so that a person on the safe side with a camera can actually see all the way through the demolition area to the other end. Unacceptable. Containment is for containing debris and air contaminants, and protecting patients and staff.  This is doing neither.  This is where you may wield your authority, and tell the contractor to stop work until the containment is fixed.  Speak to your Facilities director immediately, as they are responsible for ensuring contractors are properly trained in infection control measures, and have ultimate responsibility for ensuring it happens.  Reference for both above: CDC Guidelines for Environmental Infection Control in Health Care Facilities

So if you wander about your facility and see something that doesn’t look quite right or something you’ve not seen in other facilities, trust your gut: it’s probably wrong.  Head back to your office, find your reference, and then go correct the problem like the infection-preventing deity you are.

Mind the Gap

The APIC Megasurvey gave us a lot of information about our profession: It’s aging (we are mostly over 50), less than half of us are certified (horrors!).  But what was missing from the survey, that I consider important, is about vacancy.  How many facilities have vacancies they can’t fill? How long are postings open before being filled?  Did the hiring manager get the type of person they advertised for, or did they settle for something less?

In my area, ICPs are becoming harder to find.  I see job postings linger longer.  I hear colleagues are retiring.  I  am leaving my position soon, and gave my employer nearly six months notice, knowing how hard it is to fill the position. We had only one applicant.  A part-time position I had last year called to see if I was interested in returning--the position has been open since I left a year ago.  Smaller facilities struggle, and most US facilities are smaller--2/3rds have less than 200 beds, and 28% have less than 50, according to NHSN data.  And that’s just acute care sites.  There are nursing homes and outpatient clinics and surgery centers and psychiatric facilities--all in need of good infection preventionists, but with a seemingly small pool of qualified talent to draw from.

There is a yawning gap between some people genuinely interested in this career, and the career, because there is not always a way to take one’s suitable education and get a job whilst having no experience.  I don’t believe we have clearly laid out a path into this profession.  We are failing ourselves and our discipline. Yes, there are a few online graduate programs now, but some are MSN programs--only good if you have a BSN.

I met a lovely woman recently, looking for a US ICP job.  She “only” had international experience and couldn’t seem to get a job here.  I say “only” because I would simply die at my good fortune if a multilingual, master’s prepared, well-spoken person applied to my department fresh off a stint implementing an infection control and sanitation program in a resource-poor setting.  THIS is public health, THIS is program planning, THIS requires innovation, THIS is someone I want to talk to.   But she had no US hospital experience, and employers couldn’t see past it.

What she needed was an internship or mentorship of some kind.  Bigger hospitals or systems can mentor a new person in to the job (grow your own), but smaller sites don’t have anyone to do it, especially if the last ICP is leaving or has already left.  This is really an unfortunate set-up. Hospitals willing to do so could offer a mentorship or internship to interested professionals, as a type of schooling, but it would likely be unpaid, and thus they’d need candidates who could afford to spend several months working with the ICP, full time, for no money.  There aren’t many candidates who could afford to do that.

Also, it seems employers can’t see past the “infection control nurse” title.  You. don’t. need. to. be. a. nurse.   But the hiring manager or director is often NOT an ICP.  They are perhaps the quality manager, the nursing director, the vice president of patient care, and don’t always fully understand what skill set it takes to be successful.  The large number of nurses in any facility clouds one’s view of all of the other professions who have equal, although different, education and skills.  Some nurses are only diploma-educated.  Your respiratory therapists are much more qualified than that nurse. I can see a process management person doing well in this job.  Certainly anyone with epidemiology training can succeed.  It is the process improvement piece that is the bigger part of  this job, much bigger than the nursing piece.   Employers are limiting themselves, and very qualified people are being left out. Employers that can’t fill positions sometimes go to contract agencies.  I’ve looked at these jobs, and most list the position as “RN required.”  And I think, maybe if you changed your requirements, you would have been able to fill the position.  Now you’ve just turfed the problem to someone else.

We need a gap closer.  We need that middle mentorship piece.  We need to educate employers about the position, and what skill sets will be successful. We need to advertise the career.  The APIC Roadmap is great, once you’re in, but we need a map of the path that leads to the road.

This is what we came for

I am here as a resource: to my coworkers, to my professional colleagues, and to anyone in this career.  If I can help you in some way regarding infection prevention and control, then I am happy.   I often say to staff, “If you’ve spent more than 3 minutes on the CDC website, you’ve done too much.  Just call me.  Either I already have the answer or I know where to find it.”  Let me help you; this is why they hired me.

I don’t know everything, not even close. I’m Googling while you’re asking me a question on the phone.  But I know my resources.  You’re looking for a professional connection in your area?  Let me put you in touch with one of my tweeps or the local chapter leadership there.  Your kid has an itchy bottom and the doctor wants you to do something bizarre with a piece of adhesive tape?  Let me explain what they’re looking for and how to get a good sample.   Your patient says the other hospital staff wore gowns when treating him?  Let me call their IC department.  The hand sanitizer bothers your skin? Let me get some other samples for you.

There are certainly days when you feel overwhelmed and underappreciated, but if you continue to build your knowledge, identify your resources, and offer people calm and rational information, they will come to rely on you (in a healthy way).  And that is probably one of the best compliments you can get in this job.  Or in any job.

Here is a blissful little story from my week.  A staff nurse notes a new issue, and brings her concern to her manager.  Her manager sees that there might be an infection concern, and calls me.  She doesn’t even try to solve it, because she knows I am the resource she needs.  I identify the problem, and what we need to fix it.  I could spend hours looking for the solution, but I have something better.  I have a vendor I trust.  I send him an email that explains exactly what I need.*   Do you have a product that meets this need?  Yes.  Yes, he does.  He is my resource.  I know he has the information I need, and I don’t need to spend hours looking for it.  Surround yourself with people like this. His company isn’t our preferred vendor, but he’s my first go-to, because he saves me endless amounts of time.

Today, our solution arrived.**  The manager and I opened the packages, and I did a little dance.  It was everything we hoped for, and exactly what we needed. All the stars aligned, it was a good day, someone needed me and I came through (because someone came through for me).   I feel like I reached a little milestone in my career. It’s bittersweet because I have decided to leave this fabulous job in a few months. I work with great people who do amazing work, but I need a short break, and I’m not sure what’s next for me.  But I wish you days like this in your career, when you feel your value, no matter what your work is.

*[I need to disinfect floors in an outpatient area that has no housekeeping staff.  It needs a long shelf stability because it won’t be used often. It needs a disposable component because there is no laundry service. It must be ready to use because there is no dilution system. It needs to be compact for storage, and must require minimum PPE for handling so staff aren’t at risk mixing or diluting chemicals.]

**We got the Diversey Pace mop and the SmartMix chemicals--which is a fabulous, amazing, genius thing.  I rarely rave about anything.  But this is so exactly perfect for our setting that I’m going to gush over it as only an ICP can about disinfectant products.

Toeing the Party Line

So you say you want to work in Infection Control, but do you know what that really means? Lately, for me, it means gritting your teeth and saying things you might not whole-heartedly believe.  It means you’ll spend many valuable hours reporting data that offers little value to the patients or the public. It means you pledge to uphold published guidelines, even if the evidence is weak.  It means you don’t mind egg on your face when new evidence refutes whatever policy you’ve put into place based on those guidelines, then touted and spouted about for 2 years.

You can be a journal reader and a free-thinker and a researcher.  But if your conclusions don’t match the decade-old conclusions of a guideline-writing workgroup, you may find no support amongst your peers and little sympathy from auditors.

I can’t stand one more industry-co-written “research” article about how some instrument or device significantly reduced infections, when the study results are either not significant, important factors were not disclosed or ignored, or the intervention was a bundle when one part of the bundle is already proven to reduce contamination or infection.  But everyone is buying one.  Because of the ‘evidence’. And I look bad because I don’t buy the magic infection machine. “Oh, you don’t have one? When will you be getting one?”  Step up to the line.

I hate going to meetings to present infections that clearly aren’t, and saying “Well, this is the surveillance definition.” Nobody wants to hear that. Nobody understands why we are reporting and discussing “infections” that aren’t, those with no opportunity for improvement.  And neither do I. This AJM editorial came out recently and I briefly had fantasies of flinging a thousand copies of it into the air at the next infection control meeting and saying, ““Infection Control” isn’t even a thing.   Peace, out.”  Is my job the Truman Show?

I don’t like to be told by an inspector that the 50 hours I spent at conferences, my graduate degree in public health, my IC certification, the infection control assessment I do and the plan I write, the committee I run, and the initiatives I implement do not show evidence of my competence, and that I’ll have to come up with something else to prove I know how to do my job.

I’m on the fence about forcing people to get flu shots, and I’m about to fall off.  I believe 100% that healthcare workers should be vaccinated against communicable disease.  And for those that gripe about “their rights”, I don’t see any of them suing their parents for giving them a measles vaccine 30 years ago.  I’m frustrated by the lack of available data on EXACTLY HOW LONG FLU IMMUNITY LASTS.  Does it really cut out at the end of April? Not one second longer? Drops off to literally zero?  Like a little hourglass running out?  And how ‘bout those efficacy numbers?

But I put on my hat and tell staff they have to get a new one each year, even when it was exactly the same strains as last year’s vaccine. Have to.  Or they risk their jobs. Current recommendations from the party line.   I am, however, in favor of not hiring uncommitted clinical staff who don’t wash their hands, can’t bother to collect a proper culture, and show up sick, because they aren’t truly here for the good of the patient.  I’m in favor of hiring better staff. But I’m not sold on the flu shot mandate.  

I found a glimmer of hope, though, in APIC’s new public policy agenda.  It’s a lovely document identifying the challenges and priorities of the field, and what can be done to make improvements that do positively affect patient care and public health.  It advocates addressing gaps in knowledge and prioritizing HAI prevention activities and evaluating financial incentives.  It addresses accurate data collection (!) and standardization.  It tells me people are working on the things that frustrate me most.

The transparent agenda shows you the party line, and you can decide if it’s a party you want to join. And while the party continues to advocate for influenza vaccination mandates for healthcare workers, the agenda also contains guidance for how to lobby for change.  You are your profession, and you can participate and mold it.  So for all my frustrations, I will continue to participate and work towards change and promote the value of infection control, because I do believe in it.

But I will never wear a hand costume.

The Most Important Interview Question for an ICP to Ask

Good news: The demand for ICPs appears to be increasing.  Bad news: If you got the recent secret salary survey results from the MegaSurvey, you may be disappointed.  I’d like to think that my qualifications speak for themselves, but it’s important that we speak for ourselves also.  This is not an easy job, or not a job that’s easy to do well.  It requires advanced knowledge and constant education. Because crap just keeps happening out there in the world.  There is literally a new IC disaster of major proportions every year, if not more often.  From Ebola (horrible), to meningitis from contaminated pharmaceuticals, measles and mumps outbreaks, Zika, endoscopes, whooping cough, CRE...it’s never ending.  

So it’s important that your next employer recognizes your value, bringing all this apocalypse-averting knowledge with you. When you go for an interview, I hope you use the opportunity to interview the job, too.  Don’t sit there like a scared duckling, trying to cross the road, hoping to not get hit.  Ask questions.  Because bad jobs suck.  Employers are not likely getting a flood of qualified candidates when they post an ICP job. You are holding the cards right now. Get a good job.

I like to read other people’s CMS surveys.  You can find some of them online here: http://www.hospitalinspections.org/.  It’s like lawyers chasing ambulances:  I want to see the gruesome ones.  I want to see bad jobs where things go horribly wrong, so that it doesn't happen to me.  Here is a piece of one that I keep posted on my desktop. Possibly one of the worst:

VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES

Based on the request of documents and interviews, the hospital failed to ensure that there was an ongoing system in place for identifying, reporting, preventing, investigating, and controlling infections which included the following issues:

•     Failure to conduct ongoing active surveillance.

•     Failure to perform program evaluation and revision.

•     Failure to maintain a sanitary hospital environment.

•     Failure to maintain safe air handling in sterile processing.

•     Failure to practice safe food handling and sanitation techniques.

•     Failure to clean and disinfect environmental surfaces.

•     Failure to use disinfectants, antiseptics and germicides in accordance with manufacturers' guidelines.

The findings are:

A. Review of the Infection Control Program Manual did not indicate that the hospital had an active infection control surveillance program. In interview on 04/13/11 at 9:45 am, the Acting Infection Control Officer (ICO) stated that she walks around the hospital campus, takes notes and asks questions. However, review of the Infection Control Log revealed that none of her findings are recorded in that document.

B. On 04/13/11 at 9:45 am, during interview, the acting Infection Control Officer (ICO) was asked several questions regarding her knowledge and understanding of the hospital's infection control program. She made the following admissions:

•     That she had not been to all parts of the hospital during her rounds as the ICO.

•     That she did not document entries in an infection control log, but instead only sent e-mails to the Director of Quality (DOQ).

•     That no collection of infection control data had been done. She stated, "I probably would not have anything [infection control data] to show you at this time."

•     That no analysis of infection control data had been done.

•     That she had not monitored any negative trends identified from infection control data.

•     That she does not have a full understanding of how the infection control program is integrated into the hospital-wide QAPI. She stated, "I have not had an orientation to how the Infection Control program works with the Quality Assurance committee."

•     That she identifies and manages the Multi-Drug Resistant Organisms (MDRO), but just for the purpose of "seeing what is growing."

•     That she is unaware of how the operating rooms, intensive care units and isolation rooms' air handling system works.

•     That she had not observed a terminal cleaning of the operating rooms.

•     That she had not observed any aseptic technique practices used in the operating rooms while surgery was being performed; neither had she observed any aseptic technique employed outside of the operating rooms.

•     That she has not observed the sterilization process of surgical instruments. She admitted that she only knows where sterilization of the instruments is done.

•   That she was not able to ensure that disinfectants, antiseptics and germicides were being used according to manufacturers' instructions.

•   That her orientation to the infection control process has been inadequate.

The Director of Quality Management commented on 03/29/11 that the acting Infection Control officer "has caught on to the IC program very quickly and is doing a great job."

This is an infection control program that is NOT INTEGRATED into the facility’s operations.  The ICP does nothing and nobody notices, not even her.  If you are at your job and you are not pretty busy, something may be wrong.  She doesn’t even know what she doesn’t know.  If you fell into IC like this person, get yourself a mentor. Immediately.  A certified, qualified mentor.  [Or call me. I’ll Skype you through it.]

At your interview, you should ask: Who do I report to/ work with/ fall under and WHY?   IC doesn't really belong anywhere, because it’s everywhere.  Quality, nursing, education, patient care, administration? You want to know where you fit in. Above all, you want to know HOW INFECTION CONTROL IS INTEGRATED INTO THE FACILITY’S OPERATIONS.  Ask a million questions, but get that answer.

Some facilities just don’t know what they don’t know.  They simply do not have the infrastructure to run a hospital (or surgery center or care home, etc).  Even a place with a small number of patients needs a strong structure with qualified staff filling key roles.  And that costs money, and it’s hard to do when you have very few patients.  Some facilities simply fail to recognize the value of the IC role, or at the very least, the CMS mandate to fill that role and develop a program.  Some places pay lip service to the IC role, but offer no support.

An unsupported ICP role can be very lonely.  You may find that there is nowhere to bring your issues, or no structure to get something improved or resolved.  I often say, “I can’t wash their hands for them.”  And I can’t.  So how do you improve hand hygiene?  You need a team, you need leaders, you need accountability.  You can’t just walk around in a giant hand costume by yourself, trying to get staff to notice. It is very frustrating to work in a place that has no systems for action. If you are a team of one, who is helping you get things done?  

During your interview, you want to ask how the IC piece fits their puzzle.  When they are done asking about your strengths and weaknesses, ask “Can you tell me about a recent IC issue and how it was resolved?”  If there are none, you should be concerned.  Or this, ”How is the ICP informed about issues that arise?” If you get blank stares, this is not the job for you.  “Can you tell me about a recent PI project regarding infection control?  Who was involved in that?”

You want to know if you have support in your role.  Not on paper, but for real.  You want to talk to a few nurse managers on your second interview.  You want to talk to the facilities director, maybe the kitchen manager. Who was involved in that PI project?  You want to talk to them, and ask how they see their role in IC.  Do not take a job where you will sit in an office writing policies, never looking at or dealing with any issues. Because you are still responsible for the issues, even if you don’t deal with them!

Where does your data go?  If you have a million of one kind of infection, who knows about it, when do they know it, and is there a process improvement process? If there is moldy food in the patient refrigerators, and the nurses say Dietary should manage it, and Dietary says Nursing should manage it, what happens?  That’s a real world, every day type of problem which will be labeled an infection control issue, which will land on your desk, and unless you plan on inspecting and cleaning out refrigerators every day, you need to know what happens next here.  Do you have the authority to call a meeting? Is there an IC committee? Do you have liaisons or champions in different departments or units? If you ask nursing to manage it, will they? Who are they accountable to?  Or are you out there alone (cue tumbleweeds)?

Do not be afraid to walk away from a position that isn’t right.  There are more of them out there.  If you do find a great job, where you will be respected as the infection-preventing, staff-educating, regulatory-reporting beast that you are, then be sure to tell them what you’re worth. Because they truly don’t know.  

I hate to think that this female-dominated field is the victim of the gender wage gap...but seriously, it needs to be fixed.   So pull out your MegaSurvey results, find that measly median salary number, and bump it.  By 15% at least.  That’s your asking price.  You will not be sitting in an office crunching numbers.  You will be improving patient safety, educating staff, and integrating infection control into the facility’s operations--from Purchasing, to Facilities, to Food Service, to Employee Health, to Patient Care. Show them what an integrated program looks like.