Quality Assurance and Performance Improvement
30/30 Education Session - 30 minutes
IPs are involved in many diverse areas of a healthcare system and ensuring patient safety requires that they collaborate with many departments and understand the work that each department does—and how it impacts IPC.
This session covers the experience of a healthcare system that, out of necessity and as the result of a routine licensure visit by their state department of public health, developed a collaborative relationship between their pharmacy and their IPC team. Participants will learn the steps this community hospital took to strengthen the IP’s role in the pharmacy, particularly around compounding activities in the clean room.
The action plan, formulated by the quality and infection prevention departments, to provide better quality safe patient care included:
• Address deficiencies related to the IP’s knowledge of sterile compounding activities.
• Communicating with the pharmacy and optimizing monthly reporting to the Infection Control Committee, including a monthly environmental rounding using a tool tailored for the pharmacy.
• Educating staff on best practices including USP 797, clean room observations, policy review, and monthly clean room sampling.
• Identifying barriers to compliance, gathering staff feedback, evaluating changes, and benchmarking against measures.
By strengthening the relationship between the pharmacy and IPC, this facility was able to identify and implement sustainable process and physical changes and evaluate their impact on microbial colony counts.