Table 3.

Descriptions of Categories and Subcategories

Subcategories	Description	Exemplar Quotes
Category 1. Uniqueness of HHC: Description of HHC compared with other healthcare settings, and the different situations that agency staff encounter in various homes (eg, emotional impact, unclean homes, working alone and not knowing specific procedure)
Unpredictability of the home environment	Staff safety and other issues that are unique to working in a patient's home	“It's hard in home health. Sometimes, I'm just at a loss. How do you make this happen when these people are living in what they're living in?… Because a person can look like they got it all together on the outside, and then you get into their home and hoarding situations, infestations of animals… You just have to start and build trust.” – Administrator, Agency 6 “For me is the home environment… You can be absolutely aseptic the whole time you're in there. [But] if there's dog poop 10 feet away from you when you're doing wound care, that's a problem. Some of the home environments are not appropriate for certain kinds of patients. There's no way I can get them healed in that environment.” – Field RN, Agency 8 “Well, I think what we have done in those situations when we discover those houses, we take minimal supplies.” - Administrator, Agency 2
Need to focus on the whole fperson and situation	Recognition of the need to assess patients' home environments and social supports when developing patient care plans	You're really looking at the entire patient's psychosocial and everything. It's not as task-oriented as other areas where you're going in, and you're just doing wound care.” – Quality improvement director, Agency 3 “In the homes, we oversee just about everything. I mean, it depends on what kind of home you go in… If it's not as clean of a home, then you have more dynamics to deal with. Or if it's a dysfunctional family, you have more dynamics to deal with.” - Field RN, Agency 7
Intermittent nature of care	Discussion of the challenges related to providing intermittent care to patients and working within the constraints of ‘regular working hours’ when coordinating patient care	“As a home health [provider], we are only there X amount of hours every week with the patients. The rest of it is up to them. The rest of it is up to family.” - Field RN, Agency 4 “We have on-call at night that people may be having to be seen at night if something happens to – their wound dressing falls off or something else going on, they may need to have visits.” - Administrator, Agency 3
Staffing challenges	Difficulties faced by agency staff which are not often experienced in other healthcare settings (eg, retention, illness, workload, travel)	“More than 40% of our aides are over the age of 60. … We're struggling to recruit and replace the workforce.” - Administrator, Agency 5 “[Since] we can't secure somebody, get them through our training process before they are moving on to work for somebody else, [therefore] our RNs are actually functioning in that CNA role. So, if somebody needs help with bathing, dressing, or grooming, our RNs are picking up that duty.” – Administrator, Agency 9 “We didn't always have [supervisors]—you know, we had such turnover and now we have regular hospice nursing supervisors and clinical supervisors for home care, both nursing and therapy, so they help to make sure that their staff are adhering to [our infection] surveillance program.” Quality improvement director, Agency 1
Category 2. IPC as a priority: Description of agency and staff priorities in the context of IPC through areas of: staff adherence to hand hygiene and bag/equipment handling techniques, reducing hospitalizations, personal beliefs about IPC, and self-protection habits.
Focus on hand hygiene, bag technique, and equipment	Explanation of hand washing (and maybe sanitization too) in home environment; expectation that IPC procedures should be “second nature” to all agency staff	“We use reusable antimicrobial sheets that we lay down before we put down our bags, and just really we are stressing sanitizing between every single interaction with a patient, as well as all of our equipment.” - Administrator, Agency 8 It's just repetition, repetition, repetition. You just got to keep doing it. Then [handwashing is] going to become second nature…” - Field RN, Agency 6
Important role in reducing rehospitalizations	Recognition that infections play a major role in hospital readmissions and the need to focus on improving IPC in order to decrease hospitalizations	“Because a lot of our patients are immunosuppressed, and we're doing a lot more procedures in the home, and we have to be very diligent with infection control.” - Administrator, Agency 7 “Not only infection rates, but what's our incident rate? What is our rehospitalization rate? Those are priorities as well. I know a lot of times it's unpreventable, but we want to make sure did we do what we should have done to prevent that ER visit or the hospitalization visit.” – Field RN, Agency 9
Protection of patient/self	Particular habits or concerns that are related to IPC (like self-protection); can include personal understanding/beliefs around IPC	“…[IPC] is very important. Not just for patients but also for what I'm bringing home…I just don't want to bring anything home.” – Field RN, Agency 10 “I have different shoes when I come into my car, and then when I go home, I remove my uniform… I just leave in the garage. I don't want to come [to my house] with that.” – Aide, Agency 12
Category 3. Importance of education: Perception of how patient/caregiver and staff education about IPC impacts infections in the home environment
Staff education is vital	Recognition of the importance that staff education plays in ensuring compliance with IPC; expectation that IPC procedures should be ‘second nature’ to all agency staff	“[Staff education] is just a lot of repetition over and over until you really get used to it.” – Field RN, Agency 6 I'd like to have a better grasp of [IPC] myself. I don't feel like I know enough.” – Clinical manager, Agency 11 “I actually had no previous experience in home care or formally in infection prevention when I came to this role, which is a challenge … When I look at what resources are out there… [it is] very much geared toward the inpatient world.” – Infection preventionist, Agency 10
Education is key for patients, family, and caregivers	Discussion of the importance of patients, family and caregiver involvement in IPC and ensuring appropriate education and compliance with IPC policies	“We have to keep this in-service continuously going…that includes the education not only for our employees, but how they will transfer the knowledge to the respective families and patients as well.” - Administrator, Agency 4 “I think it's a little harder… for family caregivers to use gloves. We tell them the importance and some may understand the importance of it, but I think, because it's their loved one, they don't necessarily have that same level of importance.” – Aide, Agency 7
Category 4. Keys to success and innovation: Unique factors that help to prevent/control infections and improve quality; can include incentives, support from leadership, staff education and resources, care coordination and communication, and use of infection data to drive improvement
Culture of overall quality and patient satisfaction	Description of the agency's focus on quality improvement	“We've come a long way… [Now,] new staff are oriented to the [agency] expectations. We have a higher compliance rate, and we've had joint commission surveys where we have not had any infections tags or anything. I know in the beginning, there was a lot of education and reinforcement.” - Quality improvement director, Agency 1 “We kind of have a saying [at this agency] that doing the right thing is not always easy, sometimes it's darn well hard, but it's always the right thing to do. We try to live by that in everything we do.” – Field RN, Agency 9 “[Our leadership] makes sure you have what you need.” – Clinical manager, Agency 13
Setting up staff for success through education	Devoted resources/procedures to staff training (eg, orientation, continuing education, pamphlets) as well as retraining after outbreaks or non-compliance	“We really stay up-to-date on what's current…” – Administrator, Agency 9 “In the six months I've been here, I've seen a decrease in infections because of some of the systems that were put into place, the educational assistant, and the things that are on our charting now, our documentation.” – Quality improvement director, Agency 13
Coordinated approach to patient care	Care coordination within the agency (eg, flow of information across the agency staff, patients, caregivers and other providers) which assists, helps, motivates or is a barrier for agency staff related to IPC; direct, multi-modal communication	“When there is an update or a change in anything, that's something that we address during that [interdisciplinary monthly] meeting” – Field RN, Agency 4 “… the biggest thing that's helped us is we have secure texting, and now we can all text in a group. … It's easier to communicate” – Clinical manager, Agency 6 “We can do case communications which are a permanent part of the [patient's] record. If we're sending a message to a physician, it can be recorded that way… You can also send a message that's not a permanent part of their record, but that other staff can see. So it's the easiest way to get [the message] to everybody quickly.” – Field RN, Agency 10
Using Data to Improve Care	Description of how the agency collects infection data and how the data are used for process and quality improvement	“We found last year that our [staff flu vaccination] percentage had dipped from the previous year… We really took that as a quality initiative to really bump up how are we going to increase our rates… We were able to have almost a 12% increase last year based on the quality improvement initiatives we took. We're carrying that over this year as well.” – Infection preventionist, Agency 3 “Infection control. Well, I would say that it’s a work in progress. Our urinary tract infections have dropped a little bit, but they're still above the national average… I did have national [data] across the board from all the state… Everywhere, patients have low scores with medications. So, we developed a new tool, and our percent went up 20%. That's a big deal.” – Clinical manager, Agency 1