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Healthcare-associated infections (HAIs) are a major cause of concern because of the high levels of associated morbidity, mortality, and cost. In addition, children and intensive care unit (ICU) patients are more vulnerable to these infections due to low levels of immunity. Various medical interventions and statistical process control techniques have been suggested to counter the spread of these infections and aid early detection of an infection outbreak. Methods such as hand hygiene help in the prevention of HAIs and are well-documented in the literature. This chapter demonstrates the utilization of a systems methodology to model and validate factors that contribute to the risk of HAIs in a pediatric ICU. It proposes an approach that has three unique aspects: it studies the problem of HAIs as a whole by focusing on several HAIs instead of a single type, it projects the effects of interventions onto the general patient population using the system-level model, and it studies both medical and behavioral interventions and compares their effectiveness. This methodology uses a systems modeling framework that includes simulation, risk analysis, and statistical techniques for studying interventions to reduce the transmission likelihood of HAIs.

The purpose of this paper is to briefly review the history of healthcare‐associated infection (HAI) prevention programs in the USA since the early 1970s until today, and provide suggestions how other countries (and Canada specifically) may learn from this experience to accelerate HAI prevention and patient safety improvements in their counties.

The paper is a narrative review of literature and personal experience.

US hospitals have had healthcare‐associated infection (HAI) prevention programs, including surveillance for selected HAIs, since the late 1960s‐early 1970s. Such programs began with active surveillance for HAIs based upon the Centers for Disease Control and Prevention's (CDCs) National Nosocomial Infections Surveillance (NNIS) system. This system included standardized definitions and surveillance protocols. Since the 1980s, the CDC has developed HAI prevention guidelines, with categorized recommendations for HAI prevention. In the early 2000s, the Institute of Medicine published a report outlining the harm caused by HAIs. This led to increased attention to HAI prevention by an increasingly wide variety of organizations. The Joint Commission and the Centers for Medicare and Medicaid Services (CMS) initiated HAI prevention efforts. Many studies documented the failure of hospitals to fully implement evidence‐based practices. The increased attention to HAIs and their morbidity and mortality led to media reports and ultimately an initiative by the Consumer's Union for mandatory reporting of HAI rates by hospitals in all states. Subsequently, the CMS introduced decreased reimbursement for the additional costs directly related to HAIs (and other critical incidents) and linkage of reimbursement levels to hospital HAI rates. Together, mandatory reporting and reduced reimbursement for HAIs has led hospital executives to focus more attention on infection control programs to decrease HAI rates. Progress on preventing HAIs seems to be related to standardizing evidence‐based HAI prevention bundles, mandatory reporting, and paying for performance (or not paying for preventable HAI complications). Given that voluntary HAI prevention programs have existed since the 1970s, it appears that regulation, reporting, and decreased reimbursement has resulted in more rapid implementation of HAI prevention programs and improved patient safety.

The different major activities enhancing HAI prevention in the USA are outlined in an historic context.

Understanding the history of progress in hospital infection control efforts provides an essential perspective for policy makers and for the interdisciplinary team required to evaluate HAI mandatory public reporting in a comprehensive manner.

This editorial aims to summarize major points from and explains the rationale of a symposium convened in Canada to explore whether American experience with mandatory public reporting of healthcare associated infection (HAI) information can usefully inform Canadian policy.

The symposium brought together members of the Universities Council, an interdisciplinary consortium of Canadian and American researchers organized by the Healthcare Associated Infections Program of the Washington State Health Department. Its members are interested in patient safety generally, and a comprehensive strategy to evaluate HAI public reporting specifically.

American health department experts shared insights from their experience with mandatory reporting; Canadian experts, primarily from the British Columbia Centre for Disease Control, described the current reporting policies of Canadian public health authorities. Presentations were discussed by an audience that included members of the public, allied health professionals, academic researchers, patient safety advocates, the British Columbia Ministry of Health as well as the Canadian Institute for Health Information. The American papers presented are published in this theme issue. Participants found the symposium to be a useful discussion of important issues that identified knowledge gaps underlying the role and value of public reporting in HAI prevention. Discussion of key research agenda issues was informed by the presentations and ensuing discussions.

The Universities Council research agenda was confirmed and further informed through the presentations and discussions, affording its members and others a better understanding of current needs and opportunities. Historical and state of the art descriptions of public reporting afforded comparisons of cultures, approaches and early results that can inform any policy makers contemplating relative merits of such programs.

Despite much start‐up activity in response to demands for more transparency, indications of consumer interest, and some early claims of success, there remain fundamental knowledge gaps and coordination problems hampering achievement of best approaches and value in public reporting. The group brought together in this symposium offers one of the most comprehensive perspectives available on current theory and practice.

To explore the role of facilities management (FM) in the control of Healthcare Associated Infections (HAI) and then to discuss a three‐dimensional approach which can be used for FM services in the control of infections (HAI).

Most of what is put forward in this paper is based on a research project which is at its early stages. The discussions are therefore grounded on a thorough review of literature accomplished as part of the research project. Unstructured interviews with experts (sample – 25) in infection control in National Health Service in Scotland (NHSS), carried out concurrently as a pilot study, also provided useful insights when writing up this paper.

It is suggested that integrating FM effectively with the core services is vital in avoiding duplication of work carried out by the healthcare workers. Continuous measurement and management of performance of FM services is also vital in the control of HAI. In addition, it was identified that managing knowledge is important to retain, develop, organize, and utilize the organization's capability of managing HAI. Overall, an increased concerted effort; better integration of processes and practices between clinical and non‐clinical activities in the healthcare sector and effective dissemination of knowledge are all vital in controlling HAI to achieve “quality” in healthcare provisions. More empirical research is needed to explore the many complex and significant ways in which FM can be exploited for improved control of HAI.

Both targeted guidelines on the role of FM in the control of HAI as well as the paucity of relevant literature on related areas are limitations.

The culture of healthcare managers and functional level staff is a major implication when operationalizing the three‐dimensional approach introduced in the paper.

The paper focuses on one of the major issues in healthcare, i.e. HAI. Few have taken an FM perspective on this issue. This paper therefore adds significantly to our understanding of the control of HAI from a non‐clinical perspective.

From the symposium keynote address, this paper aims to explore how healthcare‐associated infections (HAIs) have been transformed from being only a hospital concern to a much broader public health concern.

The paper is a narrative review.

HAIs have the characteristics that define issues as public health problems. As a result, public health departments can become important partners in the evolving hospital infection control field. However, whether all state health departments can afford to add HAI experts and whether current public health department HAI activities will be effective in preventing HAIs remain important questions.

Public health agencies must be selective about focusing limited resources into areas where they can protect and improve the public's health; whether HAIs are such an area remains to be seen. Although HAIs have historically been the focus of hospitals and hospital‐based services, public health involvement has been mandated through state and federal legislation. In theory, the new mandate is appropriate; in practice, its impact and value need to be comprehensively assessed.

The interdisciplinary team required to evaluate HAI mandatory public reporting comprehensively needs to start from an understanding of the history and concepts underlying public health practice.

This paper aims to describe the initial experiences in a new option of an established fellowship program, which can serve as a model that strengthens the next generation of our workforce for preventing healthcare‐associated infections.

Historical narrative.

The CSTE Applied Epidemiology Fellowship has a long history of success in producing future leaders for the public health workforce. As it expands into a healthcare‐associated infections option, it is addressing an area new to traditional public health departments. However, this also is an area where public health must be viewed as part of the continuum of healthcare systems, where tomorrow's professionals must be credible in a number of settings (health departments, hospitals, clinics and extended care facilities).

CSTE's first class of HAI Fellows offers a new model for producing the type of professionals necessary for the field of hospital epidemiology and infection control to achieve its full potential.

This is the first published description of the Council of State and Territorial Epidemiologists new Applied Epidemiology Fellowship “HAI” graduating class.

Competing activities and projects can interfere with implementing new knowledge and approaches. The purpose, therefore, was to investigate processes and impact related to implementing two concurrent quality initiatives in a Swedish hospital. These were a regionally initiated, system-wide organizational learning programme called the Dynamic and Viable Organization (DVO) and a national initiative on stopping healthcare-associated and hospital-acquired infections (SHAI). Both undertakings aspired to increase staff competence in systematic improvement approaches.

Multiple methods were applied including surveys, observations, interviews, process diaries, documents and organizational measurements. Respondents were unit managers, change facilitators and improvement team members.

Even though both initiatives shared the same improvement approach, there was no strong indication that they were strategically combined to benefit each other. The initiatives existed side by side with some coordination and some conflict. Despite absent management strategies to utilize the national SHAI initiative, positive developments in QI culture and communication were reported. The current study illustrates the inherent difficulties coordinating change initiatives, even in favourable circumstances.

This article addresses the lesser studied but common situation of coinciding and competing projects in organizations.

This paper aims to describe evolution of a new public information web site, through evaluation‐refinement prototyping cycles.

An expanding range of participants is being engaged in formal evaluations as the site design evolves. The Flesch‐Kincaid Grade Level Score is applied to assess ease of reading in the wording used; the National Quality Forum guideline statements are applied to determine whether the prototyping design process is meeting performance expectations; and then Nielsen's heuristics are applied to evaluate ease of use of the latest prototype.

The page wordings started at a high reading grade level to be technically correct, with a strategy to progressively reduce levels without losing meaning. Reading level was reduced to an average of two and as much as six grades through editing between the third and fourth‐generation prototypes. None of the National Quality Forum principles were found missing from the development process. The prototype web site was ranked at the middle compared to official public web sites of seven other States' healthcare‐associated infection programs, some of which had been open to the public for more than a year. Many of the heuristic violations that weighed against the prototype were described as being minor and easily fixed. Collaboration between a State health department and a university to advance this evaluation‐refinement process was valuable to both parties, enhancing the ability to produce a new public information web site that is more likely to meet the needs of its intended audience.

In response to increasing expectations of transparency and accountability, a growing number of public web sites are displaying hospital performance data. Washington State's mandatory public reporting of healthcare‐associated infection rates is a recent example of this trend. The Department of Health is required by law to launch a public information web site by December 2009. The research was based on an evidence‐based approach to understand and meet the information needs of the public.

Although few studies have evaluated the usage and impact of hospital comparison web sites, these studies uniformly show relatively low usage and disappointing impact. Using the research literature, issues thought to account for poor usage and low impact, and developed design principles that address this poor past performance were identified. Throughout 2008 and 2009, successive prototypes were developed for the web site structure guided by those principles and refined each generation of prototype through focus group evaluations. This paper explains the approach, and summarizes results from the evaluations, leading to improvements before the final design first opens to the general public.

This paper seeks to provide a narrative review of some of the factors that influence healthcare consumers' information seeking involving healthcare associated infections (HAI) on the internet.

The paper takes the form of a narrative review arising from the authors' presentation and subsequent discussions that took place during the Universities Council Symposium held in Vancouver, Canada in May 2011.

There are a number of important factors that affect healthcare consumers' desire to seek information online about HAI, including the search engine used, the type of technology used, web site usability, information availability, consumers' learning style, consumers' personality traits, and finally, consumers' situational, emotional, and psychological contexts. These factors may affect healthcare consumers' decision making about where they will obtain healthcare (i.e. in their selection of a clinic, hospital, regional health authority and/or health care system).

HAI reporting via web sites is being done by health care organizations across North America. There is a need to more fully understand the factors that affect consumer use of these web sites.

Fundamental questions have been raised about the impact of providing HAI information over the WWW. There is a need to consider the varying factors that influence consumers' information seeking involving the WWW (i.e. technology‐driven and consumer‐driven factors) especially when searching for HAI‐related information about health care organizations.

Historically, HAI information was the purview of those who had a background to interpret such data (e.g. infection control and public health practitioners). The literature focusing on what consumers want to know regarding HAIs over the WWW is only beginning to emerge. More research is needed to better understand what health care consumers need to support their decision making involving HAIs.

This paper aims to examine the policy and guidance that was issued, either as a direct result of the NHS Plan, or part of a subsequent initiative, surrounding cleaning in the NHS.

A literature review of the Department of Health and related agency web sites was completed. In addition there was a literature review of the relevant academic journals.

There is a growing evidence base on environmental cleaning in the NHS and more specifically the relationship between environmental cleaning and infection control. This paper has examined the contradiction in the evidence in the suspected correlation between infection control and environmental cleaning. However, one thing that does appear to be consistent is that a performance measure based on an observation (visual) assessment is not a sufficient tool to evaluate the environmental cleanliness of a hospital ward.

While the clinical community recognise the contribution of environmental cleaning and the impact on healthcare, more needs to be done to have the relevant studies published in the FM domain. Conversely there also needs to be work done to allow the FM community to have a “voice” in the infection control journals. The literature reviewed suggests that a usable technological solution is required to confirm satisfactory cleaning standards in healthcare facilities.

There is relatively little published work on the importance of cleaning to operations in the NHS, particularly in the FM domain.