Resource Library-Expanding Our Influence as CPHQs: Strengthening an Infection Control and Prevention Program in Ambulatory Care

Video Transcription

Video Summary

The NACU Next 2024 presentation, “Expanding Our Influence as CPHQs: Strengthening an Infection Control and Prevention Program in Ambulatory Care,” describes how Columbia Doctors’ Quality Improvement and Regulatory Compliance team strengthened outpatient infection prevention without a dedicated IPC department. Framing their work within the Healthcare Quality Competency Framework (especially quality leadership/integration), the speakers share their varied professional backgrounds and how CPHQ competencies helped them respond to COVID-19 and the 2022 mpox outbreak.<br /><br />They highlight national ambulatory risks—high visit volumes, increasingly complex procedures, and fewer IPC resources than hospitals—then explain local challenges: decentralized procurement, varied instruments with different instructions for use, siloed practices, and no centralized sterile processing, requiring “lead by influence” change management.<br /><br />Using a structured performance improvement model combining PDSA, I2E2, and 6S, they built infrastructure at three levels. Strategic tools included a project charter and Gantt chart. Operational work included creating six IPC policies (hand hygiene, fingernails, and disinfection/sterilization processes) and a Qualtrics survey identifying 46 reprocessing sites. They conducted coaching tracer mock surveys across 37 sites using Joint Commission methodology, prioritizing findings via the SAFER matrix. Tactical supports included standardized logs for manual high-level disinfection and point-of-use flyers (e.g., correct wipes and contact times). Education leveraged internal LMS training, quarterly briefings, and external resources (vendor training, CDC Project Firstline/Train, and APIC ambulatory essentials), emphasizing Spalding classification and patient-centered, continuously evaluated improvement.

Asset Caption

Speakers: Ana Esteban, MPH, BSN, RN, CCRN-K, PCCN-K, CPHQ, Julie Veluya, MPH, CPHQ, Tamara Seney, RN

In this session, a team of Certified Professionals in Healthcare Quality (CPHQs) will impart insight into the myriad of burgeoning opportunities for quality professionals within the healthcare industry. This includes addressing infection control and prevention challenges as organizations continue to grapple with the continued threats of another pandemic or localized outbreaks, workforce turnover and sustainability of current efforts. Speakers will present a comprehensive approach in the application of patient-centered quality improvement tools utilized in the reappraisal of hand hygiene, cleaning/low-level and high-level disinfection, as well as sterilization practices within the outpatient sites of an academic medical center. These CPHQ leaders tackled siloed processes, identified opportunities for standardization resulting in an enhanced ambulatory infection control and prevention program.

Meta Tag

Competency Tag QLI1

Competency Tag Description Direct the quality and safety infrastructure to achieve organizational objectives.

Domain Tag Quality Leadership and Integration

Keywords

ambulatory infection prevention

CPHQ quality leadership

outpatient infection control program

medical device reprocessing

high-level disinfection logs

Joint Commission tracer methodology

PDSA I2E2 6S performance improvement

Spalding classification