Managerial Assessment

							       Unit 4.
  Managerial activities




TB Infection Control Training for
             Managers
at National and Subnational Level
                 Objectives
After this unit, participants will be able to:
• Define managerial activities needed for
    infection control at the national and facility
    level.
• Identify types of partner organizations for a
    national infection control (IC) coordinating
    body
• Identify factors to consider in assessing the
    risk of TB transmission in a facility
• Describe the elements that should go into a
    TB infection control plan
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                  Outline
Managerial activities at the national level
1. Coordinating body, plan
2. Health facility design and use
3. Surveillance and assessment
4. Advocacy, communication, social mobilization
5. Monitoring and evaluation
6. Operation research
IC plan for national or facility level
Managerial activities at the facility level

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What are managerial activities?

Activities used by program managers to
  support and facilitate the
• implementation,
• operation, maintenance and
• evaluation
of TB infection control at the national,
  sub-national and facility levels

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Managerial activities at national
  and subnational levels (1)
1. Identify and strengthen a coordinating
   body, and develop an IC plan
2. Ensure health facility design,
   construction, renovation and use are
   appropriate
3. Conduct surveillance of TB disease
   among health care workers, and
   assessment of health and
   settings at all levels
                                            5
Managerial activities at national
  and subnational levels (2)
4. Address advocacy, communication and
   social mobilization (ACSM)
5. Conduct monitoring and evaluation of
   the set of IC measures
6. Enable and conduct
   research



                                          6
1. Identify a coordinating body to:
• Adopt a national TB IC policy (after
  reviewing existing protocols and policies)
• Assess the risk of TB transmission in
  health facilities and congregate settings
• Develop a national TB infection control
  plan to include
  – A budget to reflect the costs of implementing
    the plan
  – Plans to develop human resource capacity
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Think beyond the TB programme
Is there an existing national infection control
    policy or group?
   – Such as for prevention of influenza,
      SARS, blood borne pathogens,
      hospital infections
What organizations in your country care
    about infection control?
How can (or did) you get them involved?
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       Potential stakeholders
•  Government agencies responsible for:
  – Health facilities (construction, licensing)
  – Medical services (hospitals, clinics, labs)
  – Prisons, Jails
  – Occupational Health, Labour, Finance
  – Standards, norms and codes
• Civil society: professional associations, unions,
   NGO’s, patient groups, health sciences
   universities, HIV care providers
• Private sector
                                                 9
           Coordinating body
• Establish or strengthen coordinating body
• Identify members, including IC focal person in
  the national TB programme (NTP)
• Include expertise in infection control,
  epidemiology, engineering, laboratory,
  occupational health, clinical medicine
• Determine roles, terms of reference, budget
• Responsibility and authority should be delegated
  to a specific person or leader of the coordinating
  body

                                                   10
   2. Health facility design,
construction, renovation and use
• Identify facilities conducive to TB
  transmission
  – Crowded TB, MDR-TB wards
  – Enclosed out-patient waiting areas with poor
    ventilation
  – Spaces reserved for high-risk aerosol
    generating procedures (sputum collection,
    bronchoscopy rooms, autopsy suites)
• Consider redesign or reuse of space to
  decrease transmission
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3. Assess risk of TB transmission
Where are people with infectious TB likely
  to expose others?
• Health facilities
• Other facilities where people come
  together (congregate): homeless
  shelters, prisons, refugee camps,
  dormitories, military barracks
Identify facilities
                                             12
Homeless shelter




                   13
            Surveillance
• Review TB epidemiology
   – TB prevalence
   – drug resistant TB
   – TB/HIV prevalence
• Conduct surveillance of TB disease
  among health care workers
   – define responsibilities
   – establish a register

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       Assign higher priority
        to settings where:
• TB is drug resistant (MDR, XDR)
• A larger number of people are exposed
  (crowded)
• There is failure to suspect TB
• Exposure is of longer duration (length of
  stay in the facility, diagnostic delays)
• Control measures are lacking
• Exposed people are especially vulnerable
  (see next slide)
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Groups especially vulnerable:
• To developing TB disease if infected
  with M. tuberculosis
• To dying, if develop TB
Examples
• People living with HIV
• Young children



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    HIV prevalent settings
• Health care facilities that provide
  chronic HIV care, such as ART clinics
• Counselling and testing sites
• Support clubs for people living with
  HIV/AIDS
• Prisons and jails
• Substance abuse treatment centres


                                          17
Overcrowding in prisons




                          18
Examples of at risk settings
• Vary by geography, climate, socio-
  economic status
• Inner city
• Urban slums
• Specialty hospitals (MDR, XDR-TB
  facilities)
• Nursing homes
     High risk areas for TB
transmission in health facilities
 • TB or Medical wards
 • Emergency rooms
 • Clinics to which people with known or
   suspected infectious TB are referred
 • Aerosol-generating procedures
    – Sputum collection
    – Bronchoscopy
    – Use of high speed devices during lung
      surgery or autopsy
 • Laboratories performing culture
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Review information from facility
         assessments
• How many infectious TB patients seen per
  year, by area of the facility? (MDR, HIV+)
• Patient and specimen flow: how much time
  spent in each area?
• Are high risk procedures performed?
• Is there an infection control plan, coordinating
  body, responsible person?
• Are administrative, environmental and
  respiratory protection controls in use?
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4. Advocacy, communication and
   social mobilization (ACSM)




                             22
Why enlist civil society and other
         stakeholders?
• Leverage resources, enlist expertise and
  perspectives of affected communities
• Increase sense of urgency and ownership
• Build a stake in implementing and
  sustaining effective measures
• Create demand for safe health facilities to
  expedite implementation

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   ACSM plans should include:
• Strategies for behaviour change targeting
  multiple target audiences
   – Policy makers
   – Donors
   – Health care workers
   – Patients
   – Families
• Patient-centred messages, balancing the
  interests of individuals and the wider community


                                                 24
  5. Monitoring and evaluation
• Develop IC performance indicators
• Establish a system for monitoring and
  evaluation
• Use the indicators during supervisory visits
  – What’s going well and should be reinforced
    and replicated elsewhere?
  – What needs improvement and how can the
    gaps be addressed?
  • Collaborate across programmes
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   Examples of IC indicators
• Number and percent of clinics with written
  procedures for identifying and separating
  coughing patients
• Number and percent of health care
  workers that developed TB during a given
  period




                                           26
     6. Operational research
• Can help evaluate effectiveness of specific
  IC measures or combinations
• Can assess impact (for example, by
  detecting TB infection or disease in health
  care workers)
• Can identify problem areas to be
  addressed
• Needs to be planned, prioritised and
  budgeted within a national plan
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       Infection control plan
           development
• Assign responsibility
• Base plan on surveillance, epidemiological
  data, and risk assessment results
• Prioritize TB infection control measures
  based on epidemiology and risk
  assessment
• Draft the plan
         Prioritization of TB IC
             interventions
• Base the set of measures on degree of risk:
  give highest priority to interventions with most
  impact and lowest cost
• Low- and medium-risk settings: administrative
  controls and selected environmental controls
• High-risk settings: administrative controls,
  enhanced environmental
  controls, and respiratory
  protection


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             Draft the plan

• Make plan specific to the country situation
• Base plan on level of risk
• Put plan and procedures in writing, easy to
  understand and accessible
• Make the plan Practical, Affordable,
  Comprehensive and Creative


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    Elements of a TB IC plan—
        national or facility
• Responsible authority
• List highest risk settings and how defined
• Recommended set of IC measures
• Policies
• Human resource development
• Advocacy, communication, social
  mobilization
• Monitoring and evaluation indicators
• Budget
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   Evaluating the TB IC Plan
• Develop IC performance indicators
• Establish a system for monitoring and
  evaluation, including supervision
• Repeat risk assessment
• Evaluate compliance with the plan
• Seek input from staff
• Identify impediments to implementation
• Monitor status of implementation of control
  measures
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    Revise TB IC plan as needed
•   Enlist input from health care workers (HCW)
•   Verify resources available
•   Evaluate any changes in risk
•   Evaluate changes in function or need
•   Deal with problems encountered
•   Re-educate HCW (and continue education of
    patients and visitors)



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Lifecycle of IC plan

            Develop


           Implement



Monitor,               Revise
evaluate

                                34
Lifecycle of IC plan

                Develop
                 Educate


            Implement

      Educate              Educate


Monitor,                        Revise
evaluate         Educate



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    Managerial activities at the
          facility level
• Identify and strengthen local IC coordinating
  bodies, develop a facility plan
• Rethink the use of available spaces
• Conduct on-site surveillance of TB among
  health workers, assess the facility
• Address ACSM
• Monitor and evaluate the set of TB IC
  measures
• Participate in research efforts


                                                  36
Set of measures for TB infection
   control at the facility level
• Managerial
• Administrative
• Environmental
• Personal protective equipment



                               37
                 Summary (1)
• Managerial activities support and facilitate TB
  infection control at the national and facility levels
• Potential stakeholders to involve in IC include
  civil society and the private sector, in addition to
  government organizations
• Factors to consider in assessing the risk of TB
  transmission include the frequency of TB, drug
  resistant TB and HIV in the community and in
  the facility; implementation of IC measures;
  whether aerosol generating procedures are
  performed; and the occurrence of TB cases in
  employees
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              Summary (2)
• Infection control plans should be based on
  a risk assessment
• For low and medium risk areas, the plan
  should focus on administrative controls
  and selected environmental controls
• High risk areas will require administrative
  controls, enhanced environmental
  controls, and respiratory protection
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