Implementing a Self-Assessment Tool and Continuous Quality ...

Implementing a Self-Assessment Tool and Continuous Quality Improvement Approach to
Strengthen Hospital Infection Prevention and Control Programs in Resource-Limited Settings:
The Infection Control Assessment Tool (ICAT)
Hospitals worldwide are a critical
component of the antimicrobial resistance
problem. The combination of highly susceptible
patients, intensive and prolonged
antimicrobial use, and cross-infection have
resulted in nosocomial infections caused by
highly resistant bacterial pathogens.
Resistant hospital-acquired infections are
expensive to control and extremely difficult
to eradicate. In hospitals, failure to
implement simple infection control (IC)
practices, such as hand washing and
changing gloves before and after contact
with patients, is a common cause of infection
spread. Hospitals are also the eventual site of
treatment for many patients with severe
infections due to resistant pathogens
acquired in the community.
IC is a key strategy to slow the spread of
antimicrobial resistance. Although numerous
guidelines exist, effective IC remains a concern in
developing countries fighting infections of public
health importance such as HIV/AIDS, TB, and
malaria. Strengthened IC programs are needed now
more than ever.
An effective IC program involves the complex
combination of three key types of intervention—
administrative, environmental, and personal (figure
1). A properly implemented and monitored IC
program reduces infections in health facilities,
improved quality of patient care, and associated cost
savings.
Figure 1. Infection prevention and control framework
SPS Tool for IC Self-Assessment
In most hospitals, the IC committee is overwhelmed
and underequipped to tackle this task. Strengthening
Pharmaceutical Systems’ (SPS) Infection Control
Assessment Tool (ICAT) provides hospital teams
with an evidence-based methodology and approach
to identify and prioritize IC gaps.
ICAT combined with continuous quality
improvement (CQI) methods helps identify problems
for which low-cost interventions can be developed
and implemented. The ICAT modules (box 1) cover
various aspects of hospital IC including hand
hygiene, isolation, standard precautions, and waste
management.

Each individual module contains questions for self-
assessment, a scoring system, and reference notes
outlining the current internationally recognized
practices. The modules are complemented with
checklists to help objectively assess adherence to key
IC practices. The tool can be adapted to suit local
country context.
Box 1. ICAT Modules
1. Airway suctioning
2. Employee health
3. General ward
4. Hand hygiene
5. Hospital Information
6. Infection Control program
7. Injections
8. Intensive care unit
9. Intravenous catheters
10. Intravenous fluids and medications
11. Isolation and standard precautions
12. Labor and delivery
13. Microbiology laboratory
14. Pharmacy
15. Sterilization and disinfection: equipment and
intravenous fluids
16. Sterilization and disinfection: needles and syringes
17. Sterilization and disinfection: sterile gloves
18. Surgical antibiotic use and surgical equipment
procedures
19. Surgical area practices
20. Tuberculosis precautions
21. Urinary catheters
22. Waste management
The combined application of the ICAT and CQI
cycles ensures that data will be available to direct
readjusting interventions and maintaining
improvements. IC is not the business of just the
medical or nursing staff alone, but is the result of
effective teamwork among the staff of all healthfacility
disciplines, including administrative and
cleaning departments. This combined ICAT and CQI
approach ensures sustainable improvements in IC
practices, the reduction of nosocomial infections,
and the containment of antimicrobial resistance
(figure 2).
Courtesy: Guatemala Ministry of Health and Social Assistance; adapted
from—Massoud, R., K. Askov, J. Reinke, et al. 2001. A Modern Paradigm for
Improving Healthcare. Quality QA Monograph Series 1(1). Bethesda, MD:
Published for the U.S. Agency for International Development by the Quality
Assurance Project
Figure 2. The self-assessment and CQI approach to
strengthen infection prevention and control in hospitals
Global ICAT/CQI Implementation
Experiences and Accomplishments
To date, the ICAT and CQI approach have been
implemented in Guatemala, Namibia, South Africa,
and Swaziland; and all have shown improved IC
practices and programs. The IC teams in all countries
felt strengthened and empowered by the availability
of tools to use in their work and that the data
generated served as a powerful advocacy tool for
hospital management and administrators who
became more involved in IC work. In each country,
the hospital Infection Control Committee was
oriented in the use of the ICAT and CQI approach;
the committees then developed and implemented a
quality improvement plan, which was also monitored
and evaluated.

South Africa
The national tool has been finalized.
The national-level team has been trained to rollout
the approach.
An IC specialist has been seconded to the
National Department of Health for one year.
A national infection prevention and control
manual is currently being developed.
The National and Provincial Quality
Improvement Plans for 2011/12 have been
implemented to prevent infections from being
passed on in hospitals and clinics.
Various ICAT modules are being used as
research topics by honors degree students at the
Nelson Mandela Medical School, University of
KwaZulu-Natal.
Emergency medical services (EMS) personnel in
the Free State province have been trained on the
ICAT by the provincial quality assurance staff.
ICAT has been adapted for use in EMS facilities
in the Free State Province.
ICAT implementation has begun in a large
number of public hospitals; studies have shown
significant improvement in hand hygiene and
waste management practices.
Hand Hygiene Campaign at a Provincial
Hospital, South Africa
Guatemala
A final Guatemalan version of the ICAT and user
manual was produced by the Ministry of Health
and used to roll out the approach to the national
network of 43 hospitals.
Follow-up and monitoring are being provided by
the hospital coordinators of the Vice Ministry of
hospitals; these coordinators are responsible for
supervision of the hospitals.
A surveillance system for nosocomial infections
and an obligatory monitoring system were
launched in the hospitals, whereby each hospital
has to report a few key indicators on a monthly
basis.
The guidelines for infection prevention and
control are being revised.
ICAT implementation at hospitals resulted in
improved practices as demonstrated by pre- and
post-evaluation; availability of hand washing
supplies has improved significantly.
Hand washing exercise during training in Guatemala
Guidelines and poster development in Guatemala

Namibia
ICAT has been implemented in eight hospitals.
Training of trainers has been provided; a cadre of
trainers is now available to work with hospitals
throughout Namibia to implement the approach.
The Ministry of Health has adopted the
approach, developed an IC manual, and plans to
implement ICAT in all 34 district hospitals in
Namibia.
ICAT implementation activities at hospitals have
resulted in significant improvement in hand
hygiene and waste management practices;
supplies and equipment for hand washing have
improved.
Swaziland
Hospital infection control committees have been
established.
ICAT has been introduced into eight hospitals.
Results of ICAT implementation activities
showed improved hand hygiene practices in two
hospitals.
Conclusions
The use of ICAT with CQI is a straightforward and
sustainable approach that builds teamwork and
yields quantifiable improvements in hospitals IC.
Stakeholders from the four countries have embraced
the tool as useful, adapted it to local context, and
assumed ownership, thereby promoting an IC culture
in their hospitals. Through use of ICAT and CQI,
hospitals in these four countries have implemented
multi-faceted interventions to improve practices in
certain aspects of IC, for example, hand hygiene and
waste management. Despite facing similar
challenges such as a shortage of human, financial,
and material resources, the hospitals in all countries
still managed to obtain results and improvements
with simple, locally appropriate, low-cost
interventions.
Availability of ICAT
The ICAT is available in English, French, and
Spanish. To view and download the English version,
click on the following link—
http://www.msh.org/projects/sps/SPS-
Documents/upload/ICAT-composite_FINAL_May-
2009.pdf
To view and download the instruction manual for
ICAT click on the following link—
http://www.msh.org/projects/sps/SPS-
Documents/upload/ICAT-User-Manual_Global-
May-09.pdf
For more information, please contact MSH/SPS
at sps@msh.org.
Participants at breakout session during ICAT
implementation review workshop in Namibia