Infection Prevention and Control (IPC) Assessments

• The facility requests an IPC assessment by completing the request form. If you would like to an assessment for more than one type of setting, please complete a request form for each setting. 
• The facility will identify a primary point of contact for the visit (e.g., infection preventionist, nursing director, nursing supervisor) 
  • Work with the VDH IPC assessment team over phone and/or email to schedule the site visit. 
• When requested, provide basic facility demographic information to the VDH IPC assessment team, such as facility type, number of licensed beds, and number of infection preventionist full-time equivalents. 
• Determine which staff/roles (e.g., leadership, nursing, environmental services, etc.) you would like to participate in the visit. 
• Identify a meeting or conference room at your facility to hold a portion of the visit. 

• Participate in the visit. The visit is not regulatory but is a collaboration to help identify infection prevention program strengths and areas of opportunity. 
• Together with the VDH IPC assessment team, select the infection prevention priorities on which to focus efforts. 
• The VDH IPC assessment team will then review the identified priorities and various IPC topics such as hand hygiene, transmission-based precautions, personal protective equipment, and environmental cleaning and disinfection. The topics will vary based on the type of healthcare setting. 

• VDH will send the facility a report with recommendations and resources. 
  • The recommendations report will summarize infection prevention strengths, areas of opportunity, and provide resources. 
  • An Infection Prevention Scoring Tool may also be shared, serving as a high-level summary of performance in each infection prevention category.   
    • Please check the Definitions section (below) for more information on the scoring tool. 
• The facility implements IPC assessment recommendations using tools and identified resources. 
• The facility reaches out to VDH as needed for assistance with implementing IPC recommendations (e.g., requests for help with training on a specific topic). 
• VDH will follow-up with the facility to check on progress toward addressing IPC gaps. 
  • Follow-up will occur no later than six months after the visit. This may occur over phone, email, or may include a follow-up onsite visit if needed.  
  • The facility should be prepared to share their improvement plan, current progress, and any identified barriers.  

The following definitions have been developed to assist with the implementation of elements of IPC assessment tools related to infection prevention competency, training, auditing and feedback. 

• Infection Prevention Scoring Tool: This report was developed by the VDH HAI/AR Program. It provides a quantitative measure for each infection prevention category, summarizing strengths and opportunities for improvement. 
  •  The scoring tool can be used to: 
    • Report back to facility administration in a simple, user-friendly format. 
    • Prioritize follow-up actions for areas in need of improvement. 
    • Compile and analyze scores in a systematized way statewide to identify and address opportunities under each infection prevention domain. 
• Healthcare Personnel Infection Prevention (IP) Competency: The proven ability to apply essential knowledge, skills, and abilities to prevent the transmission of pathogens during the provision of care.
• Healthcare Personnel IP Competency-Based Training: The provision of job-specific education, training, and assessment to ensure that healthcare personnel possess IP competency.
• Competency Assessment: The verification of IP competency through the use of knowledge-based testing and direct observation. If direct observation is not included as part of a competency assessment, an alternative method to ensure that healthcare personnel possess essential knowledge, skills, and abilities should be used.
• Audit: Direct observation or monitoring of healthcare personnel adherence to job-specific IP measures.