Infection prevention is a diverse and demanding job, and IPs with a Swiss-knife skill set may understandably be asked by colleagues to take on all manner of problems and projects.
Sometimes, the answer must be “no.”
“Practice saying ‘no’ out loud,” said Rachael Snyders, MPH, BSN, RN, CIC, lead infection prevention consultant at BJC HealthCare in St. Louis. “Don’t use a harsh tone, but don’t use a hesitant tone or be overly polite — strive for a steady and clear ‘no.’”
Snyders and BJC colleagues recently described their “stay in your lane” framework to help IPs navigate these difficult work situations in Minneapolis at the annual conference of the Association for Professionals in Infection Control and Epidemiology. They went through a series of questions IPs can use to guide decisions on whether a given issue falls in their scope of work.
In the current healthcare landscape, much does. IPs face multiple — sometimes conflicting — priorities. There are issues of regulatory compliance, infection surveillance, data collection, staff education, and a host of other duties that can vary widely by the IP and institution. In that regard, to the degree possible, try to clearly outline your responsibilities and make sure senior management is aware of all you are doing.
“Let’s be entirely clear — managing time is not the same as managing expectations,” said Patricia Kieffer, RN, BSN, CIC, FAPIC, an IP consultant at BJC HealthCare. “IPs have to consider others’ expectations of us. We have to be realistic in our time commitments and what we tell people we can do to help them.”
The idea for the framework arose out of the threat of heater-cooler devices to open heart surgery patients, which was the subject of a public health warning in 2015. The problem is complex, with slow-growing infections traced back to the design of some of the machines and the presence of relatively obscure waterborne pathogens in circulating water used in them. The BJC infection preventionists were involved from the outset, but the complicated response expanded to several other issues, not the least of which was that some of the machines may have been contaminated during the manufacturing process.
“As we started getting more information about this, the recommendations kept evolving, and so did our involvement,” Kieffer said. “What was the role of the IP? This is when our medical director said, ‘Ladies, stay in your lane.’”
Thus was born the idea to apply a more thoughtful process to these types of situations, allowing IPs to look at a problem and decide in a systematic way whether it is in the lane of their program. This scope will vary widely by individual and facility, but the key is to really look at your duties carefully in making these decisions, Kieffer said.
“Our jobs demand objectivity, even when evaluating the level of involvement in everyday issues that may turn into big projects,” she said. “This framework is to help you apply an objective approach to decide how you are going to get involved in some of these issues.”
There certainly will be gray areas and exceptions that individual IPs will have to address, so the framework was not presented as a panacea or an academic approach developed through rigorous peer review. “We made this up,” Kieffer quipped.
“Remember that the responses are going to vary,” she said. “Small facilities will answer these questions differently than large facilities. If you are the sole IP at a facility, you will answer these questions differently than a team of IPs.”
The framework has the benefit of a common-sense application in the real world, and hinges on three basic questions. Before getting to those, though, Kieffer suggested looking at the situation and asking at the outset, “What is the risk of doing nothing?” Consider the consequences if you choose to remain uninvolved or refer the problem to a different department, she advised.
Your decision also may be informed by your sense of the background noise at work and the perceived importance of the issue being raised, she added. While that is a subjective measure, a clear-cut piece of information is whether the issue includes some regulatory or compliance requirement involving groups like the Centers for Medicare & Medicaid Services or The Joint Commission.
“You may have to at least consult on those issues, and many times you may end up managing those,” she said.
Three Questions
Given those considerations, look at the issue objectively and ask this question: “Does it present a real or perceived infection risk to patients?”
“If the answer is ‘no,’ then that is likely an issue that you can refer out,” Kieffer said. “If the answer is ‘yes,’ then you need to move on to the next question.” That question is: Does it fall into your IP plan or roles and responsibilities? “If it is in your IP plan and risk assessment, it is likely that your involvement is going to be more than if it is outside of that scope,” she said.
If not, again consider referring it to another department. If the answer is “yes,” however, move on to the final question.
“‘Are control measures within your scope?’ That sometimes is a tough question to answer,” she said. “If the answer is ‘no,’ you may have to consult on it. If the answer is ‘yes,’ it may be one of those topics that you end up managing.”
Referring an issue to another department or colleague should be done diplomatically, and some involvement in making the connection may be required.
“When you say ‘no’ and are referring that person down another path, you may have to provide an alternative person, another department or resource,” she said. “Just because we are referring it doesn’t mean we can’t help find the right person to answer the question.”
Consulting on the issue is a step removed from managing it, but it involves more investment of time and resources than a referral.
“You are not going to manage the team, but you are going to be a part of it,” Kieffer said. “You are going to contribute to whatever intervention may be necessary, and you are going to provide information and data.”
Answering ‘yes’ to all three questions usually means the IP will manage the problem and take a leadership role in any interventions.
“Managing the issue means you are going to own it,” Kieffer said.
This responsibility could include establishing the interventions and communicating with key stakeholders.
“This doesn’t mean you have to do this in a silo,” she said. “It means that you have a team of people who are looking at this. Just because you are managing this doesn’t mean you have to do it by yourself.”
The framework can be used to address an emerging problem or to look back on a past situation and review your response. Looking back at the heater-cooler problem, Kieffer said IPs initially withdrew to their lane, but ended up taking a management role when the situation changed.
“Did it present a real or perceived infection risk? Yes, it did,” she said, running through the framework questions. “We had patients who were infected and getting really sick.”
Likewise, the incident fell within the IP plan and role, which includes preventing surgical site infections, she said.
However, when it came to the questions of whether the control measures were within the scope of the infection control program, the extent of their responsibility had been reached. They continued to consult on the issue, but were not managing it.
“We told the IPs in our facilities to talk to clinical engineering and OR staff and make sure they were following the recommendations,” she said. “We tried really hard not to manage it at that point. We wanted to stay in our lane.” However, when the CDC subsequently recommended that facilities notify all cardiac patients who may be at risk of the infections, the IP role again became front and center.
“We opened an incident command center and a call center led by infection prevention. We answered calls from patients who were calling in and we had an algorithm we worked through,” she said. “We managed it, but you see how it changed as time went on. That may happen with some scenarios and real-life situations that you are presented with as well.”
Dr. Noncompliance
In another scenario, an IP receives a call from an RN manager concerned about “Dr. Noncompliance,” a physician who is not following infection control measures for patients in contact precautions, Kieffer said.
Looking at the framework, is it a real or perceived infection risk? “It is, right? If people are not following contact precautions, they are going to transmit organisms,” she said.
Similarly, it falls within the IP plan, and the control measures are within the scope of the program. “We felt that they were because one of our roles and responsibilities is to make sure that people are being compliant with contact precautions,” she said.
So, in this scenario, the IP would talk to the physician about the issue. However, if the situation persists, the IP may need to refer the matter up to the medical staff director, she said. The framework can be used as an educational tool and a way to at least work through situations hypothetically.
“We wanted to give you some tools to start managing people’s expectations,” Snyders said. “We know that culture change is not going to happen overnight.”
Implementing the framework certainly comes with many caveats, and the framework will vary based on a variety of local factors and resources. “The hard part is going back to your facilities and talking to your co-workers, colleagues, and managers,” Snyders said. “You may even have to talk to the C-suite about why you are starting to say ‘no’ to some of these requests.”
Consider using the approach gradually to work through the ideas, maybe first applying it to workers you have a good relationship with to test out the concept and field the initial reactions.
“If everyone is used to the IP doing everything, they will not get used to you ‘staying in your lane’ overnight,” she said.
Use the framework and your list of roles and responsibilities in your program to educate others about what an IP does.
In responding to requests for assistance with issues and problems, Snyders recommends taking inventory of your current “bandwidth,” the time and resources you can commit. Consider bartering to get help in IP areas for assisting in the projects of others. In addition, you may compromise by contributing a measured amount of your time and resources, while clarifying you have other commitments and priorities.
“Show a willingness to pitch in if there are small ways you can contribute to the project,” she said. “You can be part of the team without completely managing the program.”
If you must say “no,” go ahead and give your reason, she recommends. “Be honest,” she said “Oftentimes I am guilty of this. You beat around the bush a little bit, saying you can’t do something, but you don’t really say why. Give the reason for saying ‘no,’ and I think it will really help foster a culture of transparency.”
Obviously, the framework goes out the window in “all-hands-on-deck” situations. That could include a surprise accreditation or regulatory inspection, she noted.
“And if you are the only person with access to data — even if it isn’t IP-related — you may still need to get the data,” she said. On the other hand, some IPs may find it is hard to give up control of things even if they clearly fall outside their scope of duty.
“If it’s not yours, let it go,” she said. “We struggle with this a lot. The majority of us in this room probably identify as Type A personalities. Sometimes it’s best to let things go and let others take ownership.”
Ultimately, the work culture and administrative leadership of a facility will determine whether such a framework could be used and accepted by colleagues.
“We think that gaining leadership buy-in is the key for this framework working for you and within your facility,” Snyders said. “When you are talking to leadership, keep patient safety at the center of the discussion, but remind them you are not the sole person responsible for that.”
Infection prevention is a diverse and demanding job, and IPs with a Swiss-knife skill set may understandably be asked by colleagues to take on all manner of problems and projects. Sometimes, the answer must be “no.”
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