Epidemiologist

One of the most important skills of the HE is the ability to apply the science of epidemiology to the healthcare setting. As part of his or her role, the HE must discover and understand causes and patterns of disease and adverse outcomes and apply that knowledge to improve the health and safety of patients. To adequately perform these activities, the HE should have a working knowledge of disease exposure and transmission, an understanding of measures of incidence and prevalence (and the distinction between the two), and a basic knowledge of microbiology, bacteriology, virology, and mycology.

Given the increasing shift of healthcare to the outpatient setting, the term “hospital” epidemiologist is dated and is no longer completely accurate, as the epidemiologist must monitor disease outcomes and trends among both hospitalized patients and patients in outpatient settings. A more accurate term is “healthcare epidemiologist.”

Simply put, the epidemiologist should be able to gather data, interpret data properly, and determine an appropriate course of action. Modern healthcare data, however, have become increasingly complex and are obtained from a myriad of diverse sources. To facilitate organization and interpretation of these data, the epidemiologist must also be familiar with basic biostatistics, including data analysis and interpretation; mathematics; and pattern recognition. For example, one of the most common types of data is HAI surveillance data. Calculation and interpretation of even simple types of surveillance data involves the appropriate gathering of outcomes data (ie, a numerator), exposure data (ie, a denominator), and, ideally, patient- or procedure-specific data that can be used for risk-adjustment. Another example of complex evaluation and analysis is comparing incidence rates to comparator rates, or benchmarking. Benchmarking involves comparing surveillance data from 1 location (eg, an intensive care unit) to a suitable benchmark or goal (such as published National Healthcare Safety Network rates). Benchmarked comparisons allow for critical and comparative interpretation of performance of a hospital, unit or surgeon, to help in the allocation of resources by the HE and the infection prevention/healthcare epidemiology program in general to optimize performance. However, sufficient knowledge of infection risks and patient characteristics that may affect outcomes is needed to ensure that appropriate comparisons and benchmarking is occurring.

Collectively, the principles of epidemiology and biostatistics allow the epidemiologist to focus on and recognize changes at the “population level” instead of the level of the individual patient. The epidemiologist is often called upon to interpret and explain complex population data in a concise, clear, and actionable manner.

Subject Matter Expert

An HE must serve as a subject-matter expert in many areas, including but not limited to infectious diseases, principles of infection prevention and control, antimicrobial stewardship, occupational health related to infectious diseases, quality improvement processes related to HAIs, and regulatory requirements (Table 1).

Quality and Performance Improvement Leader

The scope of hospital epidemiology has evolved and now includes a variety of roles including quality management/performance improvement. Those tools have now been applied in many other healthcare areas that are not necessarily related to preventing transmission of infectious agents. The HE is a valuable partner to the Chief Officer of Quality Improvement. Infection prevention and control is the first discipline that established the paradigm for performance improvement and use of root-cause analysis. While quality management skills may seem unnecessary to physicians schooled in traditional infectious disease, it is often a key activity involved in successful infection prevention programs.Reference Simmons, Parry, Williams and Weinstein ⁷ The HE must possess the skills to lead and manage a multitude of diverse healthcare workers (Table 1).

Included in this role is a need to understand basic concepts surrounding patient safety and how infection prevention/healthcare epidemiology programs interact with patient safety programs. Patient safety is defined as “prevention of healthcare errors, and the elimination or mitigation of patient injury caused by healthcare errors.” ⁸ Since the publication of the Institute of Medicine report “To Err is Human: Building A Safer Health System” in 1999 ⁹ and “Crossing the Quality Chasm: A New Health System for the 21st Century” in 2001, ¹⁰ patient safety, including infection prevention and control, has taken center stage in healthcare quality strategic planning. HAIs are recognized as major safety risks to patients, and, in many cases, are deemed preventable. Patient safety has also become increasingly important from clinical, public relations, and fiscal perspectives, due to public reporting of HAIs and decreased reimbursement by Center for Medicare and Medicaid Services (CMS) relative to HAIs. ^{11 , 12} As patient safety continues to grow in importance in the healthcare community, the HE should and will become more visible and will have an increased tangible impact on this arena.

A variety of skills are needed to facilitate the role of the HE in patient safety. Communication skills are necessary for discussing cases and processes with stakeholders and patients, and analytic and deductive skills are needed to analyze the events leading to an HAI or breakdown in core practices (eg, adherence to processes, errors of omission) and changes in infection rates.

Regulatory/Public Health Liaison

Infection prevention and control has increasingly become a major component of regulatory review and accreditation by groups such as The Joint Commission. ¹³ In collaboration with the infection preventionist, the HE typically plays an important role in oversight of preparation for regulatory evaluation and in the regulatory evaluation itself (ie, as a part of infection control “tracer” exercises and exit/interviews).

The HE also plays an important role as a liaison with the public health department. Some issues involve direct collaborations and communications between the hospital (which is typically represented by the HE) and the public health department. In addition, local and regional emergency preparedness pertaining to bioterrorism and pandemic influenza involves collaborative efforts between public health officials and the HE. Because the epidemiology of MDROs involves different types of healthcare institutions including long-term care facilities, ambulatory clinics and the community at large, the role of public health departments will continue to grow, and interactions and collaborations between the HE and closely allied facilities will increase in frequency, intensity, and importance.

As public reporting of HAI rates increase in frequency and intensity, the HE is ultimately responsible for the validity of publicly reported data. Many states have also included HEs on their advisory panels for the development and oversight of state HAI public reporting programs.

The HE needs to have an understanding of the structure and function of local and state public health departments. In addition, the HE needs to be well versed on infection control aspects of regulatory requirements (eg, TJC regulations), metrics used for insurance reimbursements (eg, CMS) and public reporting. During accreditation surveys, the HE often serves as a critical administrative and quality liaison between the hospital and these agencies. Finally, the HE may find opportunities to advocate for special populations (eg, children and immunizations, human immunodeficiency virus [HIV] screening and treatment programs) as a part of a community’s public health outreach.

Healthcare Administrator

Over the past few decades, the role of the HE has morphed from one that was purely focused on quality improvement to one that increasingly involves administrative responsibilities. In an era when cost savings has become increasingly important to hospitals, the HE must have expertise in budget development and in demonstrating return on investments (ROI). Because infection prevention/healthcare epidemiology program activities typically do not directly generate revenue, it is imperative for the HE to demonstrate cost-avoidance and cost-effectiveness and to illustrate how infection control expenditures improve the overall quality of an institution while reducing the overall costs. Negotiation skills for increased resources or funding are also important. Negotiating strategies, such as escalation, can be useful but can also create pitfalls, and learning how to appropriately use such strategies is critical to improving negotiating skills. It is also important for the HE to be able to understand the perspective of administrators, particularly those administrators who do not have a healthcare background or medical training, and to be able to effectively communicate information to facility leadership.

Decisiveness is an important characteristic of an HE in an administrative role. The HE often has to make decisions that impact clinical and/or administrative spheres, and sometimes these decisions will be unpopular. At the same time, he/she must always remain receptive to ideas offered by others from different areas of expertise and be willing to evaluate the pros and cons of novel strategies. The HE will also have interactions with and roles related to risk management, for example, when an HAI results in an unexpected death. An HE in an administrative role will also oversee and partake in the writing and revising of policies; effective presentation skills and persuasiveness can facilitate and improve the administrative role of the HE with regard to negotiation, decisiveness, and policy writing.

Several other key administrative aptitudes, including leadership, organizational skills, and implementation skills, are essential for HEs. Leadership involves influencing behavior to achieve desired results through efficient utilization of human and material resources. HEs should possess this skill to be successful in promoting infection prevention. Additional management skills include the ability to delegate and prioritize activities and organizing or sponsoring team activities.

Meetings consume an enormous amount of human resources, and when executed suboptimally, they often do not achieve the desired goals. The infection prevention and control committee is only one of many multidisciplinary groups whose activities involve infection prevention. HEs can facilitate efficient, effective meetings by utilizing some key organizational strategies such as advanced preparation, agenda formulation, time management, development of clear action items, and frequent requests for input and feedback from attendees.

One of the greatest challenges an HE will encounter is implementing evidence-based practices into everyday clinical routines. Several key principles and skills are needed to effectively implement system and organizational change. First, it is essential to use process-oriented thinking when designing and implementing any improvement project.Reference Balestracci ¹⁴ Using process control statistics, an HE can demonstrate variations in practices and behaviors and use human factor engineering to design interventions to ensure that the desired process is delivered in a consistent and reliable fashion.Reference Benneyan ^{15 ,} Reference Benneyan ¹⁶

To obtain meaningful and sustainable improvement, an HE must be adept at promoting both “technical” and “adaptive” changes. The “technical” approach to translating evidence into practice involves summarizing the scientific evidence, developing standardized and uniform approaches to care delivery (ie, checklists, bundles of care), and ensuring measurement and feedback of process measures to the front-line staff.Reference Pronovost, Cardo, Goeschel, Berenholtz, Saint and Jernigan ¹⁷ Additionally, Institute for Healthcare Improvement’s (IHI’s) Model for Improvement promotes incremental steps to process improvement using PDSA (Plan-Do-Study-Act) cycles to assess interventions. ¹⁸

Unfortunately, the “technical” approach alone will not ensure the consistent and reliable implementation of evidence-based practices. Root-cause analyses of serious events or near misses frequently identify issues related to lack of teamwork and failure to communicate between disciplines as important components contributing to the event. The “adaptive” components to implementing change involve addressing issues around the culture of safety on a local level with a multidisciplinary approach. The Comprehensive Unit-Based Safety Program in adults and the Children’s Hospital Association (formerly the National Association for Children’s Hospitals and Related Institutions) collaboratives for reduction of central-line associated bloodstream infections in children promote a systematic approach to improving teamwork, communication and the prevention of harm. The utility of combining adaptive and technical approaches to quality improvement is exemplified by the sustained success achieved by the Michigan Health and Hospital Association Keystone ICU Project in reducing central-line associated bloodstream infections.Reference Sawyer and Leon ¹⁹

Finally, to be an effective healthcare administrator, the HE should have skills in budget development; measuring return on investment (ROI); and economic modeling; or be able to interface with departments that are well versed in these areas.

Clinician Educator

The HE experiences numerous situations in which effective teaching and training skills are essential elements for ensuring best practices in infection prevention and control and implementing quality improvement activities. Using the clinical credibility obtained from training and knowledge from infection prevention courses, the HE is often required to translate knowledge to hospital personnel through several means.

First, the HE is expected to teach through example as a means to demonstrate best practices and ensure that medical staff performs these practices. This type of education by example is well suited for activities such as hand hygiene and the use of personal protective equipment for transmission-based precautions. Second, teaching techniques must include galvanizing area or unit champions to ensure that new and longstanding protocols and policies are introduced, maintained, and verified through methods such as checklists, logs, and patient-care rounds. This often requires teaching through personal communication with physician champions,Reference Saint, Kowalski and Forman ^{20 –} Reference Cheng, Melanee and Rawson ²² speaking at educational meetings (eg, grand rounds and nursing shift huddles), and preparing educational tools and mass messaging. ²³ Third, the HE should be familiar with formal teaching techniques through orientation presentations for new hires, development of computer-based training modules for infection prevention, and designing functional computerized prompting in electronic medical records. Finally, the HE should be integrated in a learning community behind their hospital walls. Sharing and learning is highly effective through local and regional collaborative efforts, where infection prevention program directors and staff can share written policies, quality improvement ideas, and responses to local initiatives and state mandates.

Outcomes Assessment Evaluator and Researcher

An important role of the HE is to successfully conceive of, design, and assess quality improvement initiatives to improve process measures for HAI prevention or to implement interventions to reduce the severity of outcomes related to these events. Examples include outbreak investigation, evolving surveillance definitions, and assessing the effectiveness of products for averting HAIs. Epidemiologic training provides the critical foundation for translating questions into hypothesis-driven interventions and outcomes. These skills include strategically estimating effect size, sample size (how many patients or units are needed to answer a question), and project duration (how long will it take to determine success or failure) to determine whether the project method can answer the question in the time available.

Training in analysis is equally important to training in study design. HEs need be facile with outcome assessment and must understand confounding factors that can lead to incorrect conclusions. Solutions may include partnering with other hospital programs that have robust analytic capabilities, or they may involve performance improvement teams or financial groups well versed in cost-effectiveness analysis.

While not an absolute requirement, research, presentation, and publication of findings are important responsibilities of HEs. It is critical that experiences and findings are disseminated to a wider audience to share key findings.

In conclusion, as infection prevention and healthcare epidemiology continues to evolve, so do the roles and responsibilities of the HE. The HE tackles multiple diverse responsibilities, and it is important for each HE to become knowledgeable and experienced in the skills needed to optimally address these responsibilities. Rather than focusing exclusively on surveillance and disease transmission, in today’s world, the HE must also manage issues pertaining to quality and performance improvement, regulatory readiness and public health, outcomes assessments, healthcare administration, and clinician education. While this multifaceted role is challenging, it also places the HE at a focal point of healthcare epidemiology and presents opportunities for the HE to positively influence the clinical care and safety of patients and healthcare workers.