Recommendations

1. 1. Healthcare facility administrators should support and resource a dyad leadership model for the facility’s IPC program that includes both physician and infection preventionist leaders.

2. 2. IPC program leaders should have access to senior facility executive leaders that provide prompt support for the deliverables they champion.

3. 3. Regulatory agencies and other evaluators of healthcare facility quality should examine IPC program leadership, including resource support, member competencies, and the program’s leadership model (including presence of both members of the leadership dyad), as part of their surveys of healthcare facility IPC programs.

The dyad leadership model

Leadership and the integration of the IPC program throughout the healthcare facility have been cited as one of the most influential factors for an effective program in infection prevention. ^{Reference Rechtman and Pickrell14} IPC program leaders must set and articulate goals and priorities, understand multiple, complex clinical and operational workflows, lead epidemiological investigations and analyses, and communicate and influence interested individuals and parties in multiple facilities to successfully implement processes to prevent HAIs and their associated harms.

Across U.S. healthcare facilities, leadership structures for IPC programs vary. ^{Reference Coffey, Keller and Anderson13,Reference Tan, Ofner and Candon41} CMS requires all hospitals to designate an “infection control officer,” and in many cases, this individual is also the infection prevention leader. Leaders of IPC programs have at some facilities included healthcare administrators, clinicians (both with and without a background in ID), and nursing leadership as well as individuals with a specialized focus and training in infection prevention (either a physician or an IP). Some have included a single individual charged with the oversight of the program, who also may be responsible for conducting the day-to-day activities of the program. While these leader phenotypes bring different insights to the role, to meet the raised bar of an “effective” IPC program, the program’s leadership should be filled by those with expertise and competencies in infection prevention who are allotted adequate time and resources towards IPC activities.

Given the increasing complexity of healthcare systems and the shift towards value-based care, implementation of a dyad leadership model has been utilized in healthcare facilities ^{Reference Clouser, Vundi and Cowley45} to improve communication, collaboration, and successful attainment of institutional goals. ^{Reference Saxena46} This model involves two individuals in different professions with shared responsibilities and aligned goals. ^{Reference Zismer and Brueggemann47} The literature surrounding the dyad leadership model in healthcare and its impact most often involves unit-based clinician-nurse ^{Reference Leach, Hastings and Schwarz48–Reference Clausen, Lavoie-Tremblay, Purden, Lamothe, Ezer and McVey51} and clinician-administrator teams. ^{Reference Hemker and Solomon50,Reference Baldwin, Dimunation and Alexander52} Dyad leadership structures in healthcare have been associated with improvements in communication and collaboration, staff turnover, and patient satisfaction, standardization of care; successful policy implementation and culture change; and improved physician engagement and culture. ^{Reference Saxena46} Successful dyad characteristics include clearly defined roles and aligned goals within the dyad; a norm of interprofessional communication within the dyad; external communication of the purpose of the partnership to improve clinical care; training in leadership, conflict resolution, and quality improvement; and sufficient institutionally supported time and effort for both members of the dyad to perform their duties. ^{Reference Clouser, Vundi and Cowley45,Reference Kuntz, Scholten, Wilhelm, Wittl and Hillen53}

While there are no studies of the dyad model of leadership within IPC programs, the model lends itself nicely to effective IPC programs at all types and sizes of facilities. Deemed the most successful model for IPC leadership among a qualitative survey of experts in infection prevention, ^{Reference Rechtman and Pickrell14} the dyad leadership framework opens communication across physician-administration and physician-nursing structures. ^{Reference Baldwin, Dimunation and Alexander52} Characteristics cited as leading to successful leadership dyads in clinical settings (eg, sufficient financial and institutional leadership support, effective communication) align with characteristics of successful IPC program leadership. ^{Reference Robinson, Price, Otter and Burnett54,Reference Halton, Hall, Gardner, MacBeth and Mitchell55}

The medical director of IPC

In clinical settings, physician leadership of hospitals and healthcare systems has been linked with better quality scores and reputational rankings. ^{Reference Goodall56} Inclusion of a physician in the leadership of IPC programs is anticipated to lead to similar benefits. ^{Reference Rechtman and Pickrell14} Such a role is noted here as the “Medical Director of IPC,” but it has also been referred to by other titles (Box). The intent with the terminology “Medical Director” is to utilize a role that is commonplace and familiar within many healthcare facility governance structures in order to better communicate the function of this leader. While the individual’s specific title may vary by facility, the intent is that this role directs and leads the IPC program alongside the Infection Preventionist Director. These individuals may be employed members of the hospital medical staff or credentialed physicians with an affiliated private practice. ^{Reference Wright, Ostrowsky, Fishman, Deloney, Mermel and Perl57} In some facilities, these individuals have simply chaired the formal IPC committee that periodically approves IPC policies, reviews HAI performance and notes other standing facility reports. They also may have limited to no training in infection prevention and the necessary competencies for individuals in this role (see Table 1). ^{Reference Dhar, Sandhu, Valyko, Kaye and Washer58} However, an IPC program physician leader with such limited and minimal expectations, dedicated support for, and involvement with the day-to-day activities of the program is not acceptable to consider such a program “effective.” ^{Reference Kaye, Anderson and Cook59}

Table 1. The Society for Healthcare Epidemiology of America core competencies for infection prevention and control physician personnel

Adapted from Kaye et al. ^{Reference Kaye, Anderson and Cook59}

The Medical Director is usually a practicing physician, which is an important attribute to bring to the role, as a clinician’s insights into the practice of medicine and the nuances of patient care are critical to the development and implementation of IPC processes in the clinical healthcare setting. This perspective gives the Medical Director and the IPC program additional credibility with key influential frontline and administrative personnel, allows for this role to serve as a liaison with the medical staff, and facilitates implementation of changes in HCP processes and behaviors. As noted earlier, many IPC Medical Directors are ID physicians, who are well suited for this role. The physician component of the IPC program leadership is often forgotten in guidelines on IPC program structure. Notably, the CMS CoP, while requiring a “qualified, trained” leader of the IPC program, states this leader may be an IP or other “infection control professional” but does not specifically mention a physician leader. ⁹ This gap also is present in requirements from agencies that survey and accredit healthcare facilities. The Joint Commission recently revised requirements for IPC programs among acute care facilities, but these also fail to specifically mention physician leadership as an essential part of the IPC program. ⁶⁰

The infection preventionist director

The other essential member of the IPC Program dyad leadership is the IP leader. ^{Reference Tan, Ofner and Candon41} While the role of infection preventionist is inherently a leadership role, it is critical to program effectiveness that a program have a designated IP leader with appropriate support and authority to ensure program activities occur as intended. Like the discussion above around the term “Medical Director,” the IP leader role here is termed the “Infection Preventionist Director” to note that this individual directs and leads the IPC program alongside the Medical Director, but they may be referred to by other titles (Box). Even small facilities that employ only a single IP require an IP leader to maintain responsibility over the day-to-day operations and strategic planning of the IPC program. While one individual may serve in both roles in such facilities, it is essential that that individual is empowered and has dedicated time and support to serve as such. The Infection Preventionist Director is responsible for the creation and execution of the facility’s IPC program evaluation, risk assessment, and plan, as well as all infection prevention-related policies and procedures. This individual is also responsible for ensuring all IPC program activities are conducted (eg, surveillance, rounding, practice gap identification, performance improvement interventions) and effectively communicating status and progress of program efforts with other facility leaders.

Supports and risks to successful dyad leadership

To attain an effective IPC program, the Infection Preventionist Director and Medical Director must work in partnership, providing complimentary and synergistic skills and competencies. Both the Infection Preventionist Director and the Medical Director should be considered members of the facility leadership team and should be included in multidisciplinary discussions and decisions in which infection prevention may be a factor. Together, these leaders set the strategic priorities for the IPC program and ensure alignment with facility goals, share critical information on IPC issues with senior and department leaders, and provide support for other IPC team members. The success of this dyad depends on many factors, including the organizational culture, interpersonal and personal attributes, and leadership abilities and expertise of the respective dyad leaders. ^{Reference Saxena46} Each person in the IPC leadership dyad must equally be supported by the organization and be supportive of the other leader’s expertise and contributions.

Co-leading a program can have its challenges, particularly if the goals of the two dyad leaders and the senior leaders to whom they report are not aligned. ^{Reference Rechtman and Pickrell14} Additional challenges include preference of senior leaders or frontline HCP for one dyad leader over the other. This may be due to leadership style, experience, perceived knowledge, or professional background (eg, physician versus nursing). Due to implicit, explicit, and imbalanced power distributions between physicians and other non-medical professionals, ^{Reference Saxena, Meschino and Hazelton61} however, the dyad leader relationship must be intentionally developed, with particular attention to avoiding diminishing either member of the dyad. Successful leadership teams will support each other publicly and clearly communicate shared and separate areas of expertise. Having different reporting lines for the leaders of the IPC program (eg, the Medical Director reports to the Chief Medical Officer while the Infection Preventionist Director reports through the quality program or nursing leadership) may bring ambiguity to decision-making, goal planning, and implementation strategies and can lead to confusion within the program.

Differences in protected time for their roles may also jeopardize the success of the dyad leaders. For example, the Medical Director may have significant clinical responsibilities that restrict the amount of time that is dedicated to IPC program work. This is especially a risk where the Medical Director is provided a limited amount of focused effort to support this role (eg, only support for a small percentage of salary or on a limited hourly basis that does not allow full involvement in the expected spectrum of activities of an effective IPC program). These physicians often appear as consultants rather than partners to the Infection Preventionist Director. Other threats to the dyad are related to Infection Preventionist Directors with additional responsibilities beyond strategic planning and managing the full IPC team, including acting in the roles of the IP team members covering clinical units and performing surveillance for HAIs. If the Infection Preventionist Director “counts” as a regular team member in the budget, they are often unable to hire additional staff to backfill their day-to-day role and responsibilities. These additional roles may cause the Medical Director to appear more available and “in charge,” having more dedicated time for IPC program oversight and work. Infection Preventionist Directors who are the only IP members of IPC team will manage all facets of the IPC program and may not have enough protected time to interact with facility leadership or strategically plan for the IPC program. These variations in team structure, leadership support, and role expectations affect how the dyad is viewed by leadership and colleagues and can impact the success of the program.

Recommendation

Healthcare facility leaders and regulatory partners should ensure that IPC program personnel are trained and have the core competencies outlined for these specific roles, including providing expectations and support for training when needed.

Essential to the structure and effectiveness of the IPC program is ensuring that the members of the IPC program demonstrate the core competencies and skills necessary for their roles. For the two main groups of IPC personnel, physician and IP, there are previously outlined competencies (see Tables 1 and 2) that should be expected for individuals serving in these roles. In addition, such training should be ongoing throughout the individual’s career to incorporate the emerging knowledge and science around infection prevention. Importantly, some individuals hired into the IPC program may have a background or understanding around some of these competencies but lack a complete understanding and training in all the essential skills and competencies. For example, an ID physician may understand the clinical management of infectious diseases yet still needs further training in epidemiology and infection prevention practices to effectively function in an IPC role. Likewise, an IP with a nursing background will need training in other aspects of the IP role such as surveillance methodology, microbiology, and epidemiology. As such, facility leaders should set expectations for and support training for such individuals to attain the full range of these skills and competencies.

Table 2. The Association of Professionals in Infection Control and Epidemiology infection preventionist (IP) competency domains ^{63–Reference Bernard, Hackbarth, Olmsted and Murphy66}

For physician IPC personnel, SHEA has outlined roles and associated competencies, knowledge expectations, and skills. These are briefly summarized in Table 1 but are outlined in detail in the position paper by Kaye et al. ^{Reference Kaye, Anderson and Cook59} A certificate in healthcare epidemiology and IPC is also available through a SHEA/CDC training course. This course, or its equivalent, is taken by many IPC program physicians, and some facilities and states have required such training for their physician IPC personnel as a measure of IPC competency.

Likewise, APIC has developed a set of competencies outlining the essential knowledge and skills for an IP. This competency model was first described in 2012⁶² and has been updated (most recently in 2019) as the field has evolved. ^{63–Reference Bernard, Hackbarth, Olmsted and Murphy66} The model includes six domains meant to guide IPs in their career and leadership development (see Table 2). Subdomains are included in each domain which expand the specific skills, knowledge, and training required. ^{Reference Tan, Ofner and Candon41} IP specialty training typically occurs on the job; however, there are some academic programs that offer IPC degrees, diplomas, and certificates. Future academic pathways to the IPC profession are currently in development by APIC. ⁶⁷

IPs should obtain certification, through the Certification Board of Infection Control and Epidemiology (CBIC). ⁶⁸ Certification in Infection Control through CBIC “supports higher salary compensation, increases job satisfaction through a structured career development framework, improves patient outcomes, advances evidence-based infection prevention practices, and is valued by the public and within the health care industry.” ^{Reference Marx, Callery and Boukidjian69} Additionally, certified IPs may have a stronger understanding than other practitioners of the evidence for certain IPC practices and are more likely to recommend implementing such practices in their own facilities. ^{Reference Hsu, Zhou, Nosakhare and Marsteller70} Facilities should demonstrate that attainment of certification is a priority by dedicating appropriate time, resources, and support to IP staff to attain this level of expertise.

Infection preventionists team members

In any IPC program, there is a need to have core members to conduct the key activities of the IPC program. Reporting to the Infection Preventionist Director, these individuals have similar core competencies and are the primary team members responsible for conducting HAI surveillance, partnering with frontline personnel to audit and train on expected IPC practices, facilitating IPC improvement programs, and conducting IPC risk assessments across many aspects of the facility. IP core team members may have a concentrated focus in specific populations (eg, assigned to areas and activities in a specific clinical area) or on specific IPC activities (eg, in a centralized HAI surveillance role).

Associate physician experts/epidemiologists

In addition to the Medical Director role, there is often a need, particularly for larger and more complex facilities, to include and provide support for additional physicians with IPC expertise on the team. This allows for concentrated focus in core areas (eg, a pediatric ID specialist to oversee the IPC program activities in pediatric units) as well as efficient and nimble physician guidance during times of unpredictable surges in IPC events or issues. As with the Medical Director, these individuals should have training in the core IPC competencies and be provided with adequate support and protected time to allow for a full focus on the IPC program activities and goals. The Medical Director should provide direct supervision, guidance for day-to-day activities, and mentorship to these colleagues. In addition to the physician and IP personnel, the IPC team, particularly in larger facilities, may also include individuals such as non-physician epidemiologists, who work with the IPC team, providing advanced expertise around key epidemiologic issues, assessments, and projects related to the program.

Data scientists

Data are essential in IPC program efforts, as they provide insights into program effectiveness and impact, identify new or under-controlled harms, and drive improvement. Data scientists serve to compile, analyze, and display data internally (eg, such as with efforts to display infection trends to frontline staff, institutional oversight committees, and leadership) and externally (eg, as is required by CMS, state and local health departments, and assessors of institutional safety and quality). These specialists can assist with large-scale data mining from available institutional sources like the electronic health record to aid with process improvement projects and epidemiologic investigations (eg, disease outbreak investigations). ^{Reference Frankel, Haraden, Federico and Lenoci-Edwards71} With the advent of artificial intelligence (AI) and machine learning and their uses by IPC programs, these specialists will be increasingly important for the IPC program mission.

IPC practice auditors

One key distinction of an effective IPC program is the proactive and comprehensive assessment of IPC practices throughout the facility, often completed through direct audits and observation of practice (eg, hand hygiene observations and environmental cleaning audits). To fully perform this function, some IPC programs, particularly those at larger facilities with a more complex range of patient populations and services provided, will need personnel dedicated to auditing frontline practices. They can also play a key role in real-time feedback and education to frontline personnel on core IPC expectations.

Administrative support

As with any other foundational facility program, the IPC program must be provided with administrative support to manage the important logistics of the IPC team. These include but are not limited to scheduling, office maintenance, and documentation of meeting activities. These core personnel will allow the other IPC team members to operate at the top of their expertise to lead and run an effective IPC program. In some instances, this role may need to be expanded into the role of a program manager who can coordinate the activities of a core component of the IPC program (eg, an individual who coordinates the institutional hand hygiene program).

Recommendation

The IPC program, including its leaders, should be staffed and supported to allow ample time for completion of all IPC responsibilities.

The SENIC study noted the impact of a better-resourced IPC program on the control of HAIs. ^{Reference Haley, Culver, Morgan, White, Emori and Hooton17} That study demonstrated that the presence of one “infection control nurse” (ie, an IP) per 250 beds, a physician dedicated to the IPC program, and a system of reporting infection rates to surgeons was associated with a 32% decreased infection rate. The size and complexity of hospitals and healthcare systems have increased substantially since this seminal study. A later analysis from a large teaching hospital observed 1.6 million patient days of HAI surveillance and determined that increased IP staffing and the presence of an IPC program physician were associated with lower rates of HAI outcomes. ^{Reference Clifford, Newhart, Laguio-Vila, Gutowski, Bronstein and Lesho72}

Assessments of and recommendations for staffing of an IPC program are limited and often are focused on IPs. In 2018, the APIC MegaSurvey noted a median IP staffing rate of 1.25 IPs per 100 inpatient census beds. ^{Reference Pogorzelska-Maziarz, Gilmartin and Reese73} There were significant differences in IP staffing, duties, and support between smaller and larger facilities. With the advanced complexity of patient populations and healthcare procedures, including an expanding ambulatory scope of healthcare, use of occupied or licensed bed size as the sole metric to assess staffing is no longer useful and underrepresents the resource need for an effective IPC program . A report from 2002 recommended that, in addition to facility bed size, the scope of the IPC program, complexity of the health care system, characteristics of the patient population, and the unique needs of the facility and the community must also be considered. ^{Reference O’Boyle, Jackson and Henly74,Reference Bartles, Dickson and Babade75} A large nonprofit health system systematically quantified IP staffing needs, including in acute care settings and continuum of care sites such as ambulatory, long-term care, and home health. They determined a benchmark of 1 IP full-time equivalents (FTE) per sixty-nine beds using this approach. The authors emphasized that the scope of services, population, as well as size of the facility must be considered in determining IP staffing needs.

While formal recommendations about Medical Director and physician staffing remain rare, the SENIC study noted the presence of a trained physician as part of an effective IP program. An infrastructure report from members of SHEA in 2016 included recommendations for physician support that included considerations of the complexity of services provided and facility size. ^{Reference Bryant, Harris and Gould76} For academic-based institutions, hospitals with ≥300 beds and/or ≥50 intensive care unit beds, ≥ 1.5 FTE of a physician full professor salary was recommended, and for hospitals with < 300 beds and/or < 50 intensive care unit beds, ≥1.0 FTE of physician salary was recommended. For community-based hospitals with ≥300 beds and/or ≥50 intensive care unit beds, >1.0 FTE of physician salary was recommended, and for hospitals with <300 beds and/or <50 beds, ≥0.5 FTE of physician salary was recommended. As with the earlier recommendations for IP staffing, these guidelines did not fully account for the complexity of services provided, patient population, or larger continuum of care.

The Department of Veterans Affairs released a directive in 2017 (amended in 2021) that outlined the minimum staffing requirements for their facility’s IPC programs, including both the Infection Preventionist Director and Medical Director roles. They note the requirement for both an “Infection Prevention and Control Professional” (ie, IP) and a “Hospital Epidemiologist” (ie, physician that is “preferable to be an infectious diseases trained physician”) as part of the program. Importantly, they specifically note that “[t]he responsibilities for hospital epidemiolog[ist] are independent of clinical workload,” highlighting importance of providing enough dedicated time towards the IPC program to conduct the program work. Based on the facility complexity, there are levels of support for core IPC personnel as well as other requirements for the IPC program, including space and information technology and data analytic access.

In 2016, the World Health Organization (WHO) released expected core components of facility IPC programs with updated assessment tools released in 2023. ^77,78 These include expectations on IPC team members, objectives, and functions; IPC education of HCP; HAI surveillance; HAI improvement interventions; audit and feedback of IP practices; environmental controls; and facility staffing and bed occupancy. Notably, while the WHO recommends having a “dedicated, trained” team in place as part of the IPC program, specific expertise and leadership of the program is not noted nor is there an explicit mention of the need for physician leadership over the program. The WHO report recommended a minimum ratio of one full-time IP for every 250 beds but also noted that a higher ratio (eg, 1:100) should be considered. The 2023 assessment tools are stratified by facility type (primary, secondary, and tertiary) and note the same expectation for trained IPs (with ratio of one full-time IP:250 beds again noted for secondary and tertiary facilities), yet IPC leadership and reporting structures are not addressed.

Given the importance and impact of IPC programs, it is surprising that there are limited guidelines or requirements around IPC program composition, leadership, and support. With many studies focused only on inpatient bed size as the measure of the population at risk for infectious threats at a healthcare facility, resource statements on IPC staffing underestimate the true need, particularly with the raised expectations for a fully effective program. To guide facilities on an assessment of the resource needs to support an effective IPC program, APIC has created a staffing calculator that accounts for the healthcare facility’s size, practice type, patient population complexity (eg, pediatric, immunocompromised, and trauma patients) and services provided (eg, transplantation, congregate living). ⁷⁹ This tool provides a recommended range of IP staffing support.

We have also crafted a framework tool with recommendations around levels of expected support for the IPC Medical Director and other physician personnel (as applicable). This framework accounts for differences in facility volumes, demand, and complexity that would warrant a greater level of physician support to fully direct and address infection prevention issues in increasingly complex and busy centers (Table 3). Future versions of the APIC calculator will also expand to include recommendations on physician (using this framework in part) and other core member personnel support to guide facilities and other partners on expected staffing for IPC programs.

Table 3. Medical director of infection prevention and control (IPC) and IPC physician support recommendations

FTE = full time equivalent; AHA = American Hospital Association; AHRQ = Agency for Healthcare Research and Quality; OPTN = Organ Procurement and Transplant Network

Example application of this framework: A 250-bed facility examines IPC physician support by starting with the recommended baseline support in Step 1 (0.50 FTE or equivalent). Based on the facility’s volume (i.e., if it is lower or higher than national 25th/75th percentiles respectively), complexity of the population served, or other factors noted in Step 3, the baseline support may need to be increased (e.g., through increased funding of the single Medical Director or addition of more IPC physician personnel) to fully meet the expectation of an active and maximally effective IPC program.

Multiple factors must be considered in determining baseline levels of support for IPC program Medical Director and other physician roles. As highlighted above, literature on IPC program staffing traditionally has been solely focused on the IP role, so any current recommendation for physician support is going to be largely based on expert opinion, as was used to set the recommended baseline support ranges in the framework table (see Supplementary Material, Appendix 2). In addition, many facilities may not currently support their IPC physicians with the minimally recommended levels noted in the framework. This is not unexpected, as the driving goal of this paper is to advocate for IPC programs to maximize their effectiveness and address all infectious harms. Facilities with under-supported IPC physicians may not have set expectations for these program members that fully align with a maximally effective IPC program, and they will need time to provide increased support and expectations around their IPC program personnel. It is also imperative that IPC physicians have dedicated time to commit to the breadth of expectations of their role and to avoid creating conflicting demands between physician clinical work and effort devoted to the IPC program. Such support provides the consistent presence and perspective of the IPC physicians that may be lost with more sporadic support for IPC program participation.

Recommendation

Facility personnel not directly supported under the IPC program but whose roles and activities impact and affect the mission and goals of the IPC program should have alignment of their performance goals that include partnership with and focus on IPC activities.

Creating a fully effective IPC program involves partnerships with personnel from other key facility departments and entities. These personnel have expertise and roles that can directly impact the effectiveness of the IPC program, both positively, if their work aligns with IPC goals, and negatively, if the goals and priorities of their program run counter to those of the IPC program. For example, a facility’s environmental services (EVS) program that places priority solely on rapid and efficient room turnover could directly reduce the effectiveness of the IPC program if such rapid turnover does not allow for adequate time to clean the patient rooms thoroughly and reduce the risk of transmission of contagious pathogens. The support and resources for these partner personnel are budgeted separately from the formal IPC program. As such, to have as effective an IPC program as possible, healthcare facility leaders should set expectations for each of these partners that includes alignment with IPC goals and appropriate resources to meet those goals. Several key partners and their specific influence upon IPC goals are noted below:

EVS personnel

Pathogens can survive in the environment for prolonged periods of time, and EVS personnel play a key role in preventing infectious pathogen transmission in the facility. Their work in ensuring regular cleaning and disinfection of surfaces, equipment, and the facility environment reduces the risk of transmission of infectious pathogens throughout the facility.

Occupational health (OH) personnel

HCPs are subject to a myriad of infectious disease risks in the day-to-day care of patients. A facility’s OH program and personnel are responsible for ensuring a safe workplace, and partnership with the IPC program can effectively monitor and address potential infectious disease harms for HCP. Specific examples include evaluation and audit of personal protective equipment use when caring for patients in isolation precautions, adherence to Occupational Health and Safety Administration requirements to reduce bloodborne pathogen exposures, implementation of interventions to reduce the presence of infectious persons in the facility (whether visitors or other HCP), and oversight of the facility immunization programs for both HCP and patients.

Microbiology and laboratory personnel

Many HAIs are identified by testing and processes centered in the microbiology laboratory. Laboratory personnel impact IPC programs through their work towards the prompt detection of infectious organisms, often using newer molecular methods for diagnosis and surveillance, which allows for early identification and isolation of colonized or infected patients. Microbiology colleagues also play a crucial role in outbreak management through rapid identification of cases, molecular sequencing to determine relatedness of possible clinical cases, and partnering with state and referral labs if needed for additional testing or environmental cultures to identify a common source for the outbreak. IPC program members also partner with laboratory leaders on diagnostic stewardship programs to optimize the assessment of patients with suspected or confirmed infectious diseases while minimizing false positive results and associated waste and overuse (eg, unnecessary testing and treatments).

Industrial hygienists

These specialists play important roles to ensure a safe and healthy environment for patients and HCP through assessments of the environment and implementation of measures such as engineering controls (eg, improve ventilation, install physical barriers) to help mitigate spread of infectious pathogens. They work closely with the IPC program to stay up to date on industry-specific standards, assess risk and assist with outbreak response, if needed.

Informatics/Information technology specialists

Much of the work of the IPC program involves rapid detection of HAI activity increases and assessments of provider compliance to core infection prevention practices. Facility informatics specialists leverage the electronic health record and other data systems to aid IPC activities, such as through the development of tools for automated surveillance for HAIs, decision support interventions that decrease unnecessary laboratory testing, communications for contagious disease notification, and rule-based alerting and automatic ordering of key IPC actions (eg, automated placement of patient isolation orders when a resistant organism is detected). ^{Reference Mann, Ellsworth and Huda80,Reference Hota, Jones and Schwartz81}

Emergency management personnel

The importance of these experts has been highlighted by experiences with recent outbreaks and pandemics such as those related to Ebola Virus Disease and COVID-19. Their expertise synergizes with that of the IPC program personnel, with an aligned goal to reduce the spread of novel infectious pathogens in the facility. They work to assess risks, establish communication protocols, facilitate coordination with various key parties (eg, community organizations, public health agencies), streamline and address supply chain vulnerabilities and shortages (eg, for medications, protective equipment), and direct resources to areas of most need. With the recently revised requirements from The Joint Commission that include two new elements of performance to enhance facility preparedness for high-consequence infectious diseases or special pathogens, partnerships between IPC programs and emergency management personnel will become even more important. ⁶⁰

Supply chain personnel

Individuals who manage the facility’s inventory of supplies are key partners with the IPC mission. Working with the IPC program to identify products that reduce infectious risks (eg, safety sharp devices) as well as whether products espoused to lead to HAI reductions (eg, antimicrobial coated devices) are necessary for the facility to meet IPC goals. Other examples of the supply chain IPC partnership include responding to product recalls due to pathogen contamination and standardizing facility disinfectants and hand hygiene products.

Sterile processing and device reprocessing personnel

The risk of pathogen transmission from inadequately sterilized or reprocessed devices is a growing concern that can lead to direct patient harm and substantial financial and reputational harm to the facility. ^{82–Reference Delmonico85} Issues related to improper instrument sterilization and device reprocessing were a leading source of facility citations by The Joint Commission in 2023, including immediate threats to patient safety that can result in substantial facility penalties. ⁸⁶ Linkage of the goals of the IPC program with those of the sterilization and high-level disinfection programs is key to reduce infectious risks to patients, ensure standardized performance of sterilization and reprocessing practices, and minimize institutional risk.

Implementation experts

These specialists often have a background in quality improvement with specific training in a variety of improvement strategies (eg, LEAN, Six Sigma), and work to ensure that institutional policies, including those specific to the IPC program, are implemented effectively. ^{Reference Bryant, Harris and Gould76,Reference Mann, Ellsworth and Huda80,Reference Hota, Jones and Schwartz81,Reference Collins, Dumkow, Kufel, Nguyen and Wagner87–Reference Benbachir89}

Recommendation

The IPC program and its dyad leaders should have an organizational structure that allows for alignment of duties and responsibilities.

The effectiveness of an IPC program is influenced by its reporting structure, affecting communication, collaboration, and the implementation of preventative measures. Of critical importance for the IPC program is ensuring direct reporting or regular access to an executive who will provide prompt support for IPC projects and policies. ^{Reference Leach, Hastings and Schwarz48,Reference Baldwin, Dimunation and Alexander52,Reference Billings, Bernard and Caffery64,Reference Frankel, Haraden, Federico and Lenoci-Edwards71,Reference Brannigan, Murray and Holmes90–92} There is no national standard for IPC program structure, however, with some programs directly reporting into the healthcare quality department, while others through nursing or physician leadership. The dyad leadership relationship needs to support IPC-related clinical, quality and safety initiatives, reduce barriers with IPC practice and policy implementation, and achieve core outcomes in quality and safety. ^{Reference Leach, Hastings and Schwarz48} Such work will be more successful in the presence of organizational alignment. Importantly, irrespective of the IPC program reporting structure adopted at the facility level, it is important to have alignment in reporting for both dyad leaders.

With the multidisciplinary nature of engagement of the IPC program, a common reporting structure is through the quality department. Reporting to the institutional quality leader, such as the Chief Quality Officer (CQO), offers several advantages. The CQO is responsible for data-driven decision-making and performance measures across the health care organization. ^{Reference Frankel, Haraden, Federico and Lenoci-Edwards71} By reporting to the CQO, as long as that individual is part of the facility’s core leadership with the ability and expectation to direct and influence institutional practices and policies, IPC efforts may be better aligned with the organization’s strategic goals and have appropriately allocated resources. The IPC program will have easier access to relevant data and analytics resources, facilitating evidence-based decision-making. This support is essential for tracking infection rates, identifying trends, and implementing targeted interventions. Certain root causes of higher HAI rates, such as the frontline staff’s ability to perform expected practices consistently and reliably, can also lead to other safety harms which would be under the CQO’s purview. Furthermore, as IPC teams are closely tied to regulatory requirements and accreditation standards, the CQO typically oversees compliance efforts. With a unified reporting structure through quality, the approach will be more coordinated to meet regulatory standards and reduce the risk of noncompliance and potential penalties. Due to the natural synergy between the IPC and quality programs, it seems reasonable to have an IPC team report into the quality structure to contribute best to a culture of continuous process improvement. ^{Reference Leach, Hastings and Schwarz48,Reference Baldwin, Dimunation and Alexander52,Reference Billings, Bernard and Caffery64,Reference Frankel, Haraden, Federico and Lenoci-Edwards71,Reference Brannigan, Murray and Holmes90–92}