Infection prevention and control effectiveness and safety: Validation of a survey for long term care facilities

Objectives First to develop a short survey based on the 2004 Health Canada / Public Health Agency of Canada recommendations for key infection prevention and control (IP&C) structures and processes in long term care facilities and the five Institute of Medicine safety principles published in ‘To Err is Human’ (2000). Then, to establish the validity and feasibility of the survey when used to describe key IP&C structures and processes in LTC facilities within the context of the five safety principles. Methods This study was designed using a three-phase methodology. During Phase I, a conceptual model for IP&C was created to develop six structural and process composite indices. The concepts and components covered within each index were developed based on the 2004 Public Health Agency of Canada recommendations for IP&C programs in the LTC setting and a thorough literature review. During the second phase of the study, a group of 7 experts in LTC IP&C were recruited from BC’s Provincial Infection Control Network to validate and further develop the survey and one of these dropped-out at the beginning of the process. The five Safety Principles published in 2000 by the Institute of Medicine were also provided to the experts so they could be used to complement and further develop the concepts covered by the survey. The Delphi methodology was used in this phase of the study so that experts may reach consensus on modifications made to survey questions. The Delphi phase began in April and ended in October 2007; 114 worksheets were sent to experts to support the consensus-reaching process. Consensus was defined as 67% concordance of opinions and experts were given almost unlimited time to respond to worksheets. Once the validity of new survey questions had been established based on expert-group consensus in Phase II, a second draft of the survey was prepared and pilot-tested in Phase III. An invitation letter was sent to a random sample of 20 LTC facilities stratified by facility ownership and governance structure in Fraser Health. The 14 facility Senior Managers who agreed to participate were sent a cover letter and electronically fillable survey. An analysis of the validity of the survey questions and the feasibility of the use of the survey in a larger study was performed, and revisions were made to the survey based on the findings of this analysis. Conclusions The three-phase methodology used in this study was very useful and innovative way to further develop and validate the literature-based survey developed in Phase I for IP&C in long term care. In addition, by merging two bodies of knowledge and thought into the process, concepts and components that are not explicitly described in IP&C literature yet were felt to be key in program success, were incorporated into the measurement tool. Using Delphi, the experts expressed a need for IP&C professionals working in LTC to increase their knowledge, understanding and use of safety theory and strategies. They also felt that interdisciplinary work, the development of a culture of safety, and the development clear and simple IP&C systems are key ways in which infections can be prevented and outbreaks quickly controlled. In Phase III, the pilot-study analysis demonstrated the utility, validity and reliability of the survey. In addition, the analysis showed that there is a tendency for facilities to have lower levels of components within the Leadership Index and the ICP Index. If confirmed in a larger study, this would be a major concern as all studies and expert advisory bodies for both IP&C and safety state that a strong, dedicated and knowledgeable leadership is the key to program effectiveness. Further validation of the survey and score calculation methodology should now be performed when the survey is used in a larger study.