Opening Day Is Only the Beginning: The First 90 Days of IPAC in a New Long-Term Care Home

Opening day in a new long-term care home feels like a finish line, and understandably so. Months, sometimes years, of planning have gone into getting to that moment. The building is ready, staff have been hired and trained, policies have been prepared, supplies have been ordered, and residents are finally moving into their new home. There is an enormous amount of work behind that achievement.

From an infection prevention and control (IPAC) perspective, however, opening day is not really the finish line. In many ways, it is the first time we get to find out whether everything we planned actually works.

Before residents move in, many aspects of the IPAC program exist under controlled conditions. We can determine where PPE will be stored, develop surveillance processes, write outbreak plans, educate staff and decide how audits will be completed. All of that preparation is important, but a plan that looks good before opening can feel very different once staff are caring for residents, documentation is accumulating, supplies are moving through the building, and several priorities are competing for attention at the same time.

That is why I believe the first 90 days of IPAC in a new long-term care home should be treated as a deliberate period of stabilization.

I often think about this as roughly the first 30, 60 and 90 days, although those numbers should not be interpreted as rigid deadlines. Every home will stabilize differently. The value of the framework is that it forces us to recognize that opening a home and operating a home are two different challenges.

Having an IPAC program is not the same as having one that works

A new home can have all of the pieces we normally associate with a functioning IPAC program. There can be policies, audit tools, surveillance forms, hand hygiene products, PPE, environmental cleaning processes, outbreak plans and staff education. On paper, everything may appear ready.

The question after opening is whether those pieces actually work together under real operating conditions.

Ontario requires long-term care homes to maintain an IPAC program that includes an interdisciplinary approach. The responsibilities assigned to the IPAC lead include overseeing education, auditing IPAC practices, conducting regular infectious disease surveillance, supporting outbreak management and implementing improvements identified through audits or by the home. Those are not isolated activities. They are parts of a system that depends on information being collected, problems being recognized, and leaders actually responding to what they learn.

Current LTC best practices take a similar approach, describing surveillance, education, policy development, case management and other activities as core IPAC program functions. The guidance also makes an important point that can easily get lost during opening: some IPAC functions need to be available continuously, including outside normal weekday hours.

That is where the first few months become so important.

The first 30 days: learn how the home actually works

During the first several weeks, I would resist the temptation to treat every problem as an isolated deficiency that needs an immediate educational response. Some issues absolutely require immediate correction, particularly when resident or staff safety is involved, but this period also provides an incredible amount of information about how the home actually functions.

Before opening, we make reasonable assumptions about workflow. We decide where supplies will be stored, how information will be communicated, who will complete surveillance, how environmental cleaning will be coordinated and how staff will respond when a resident develops symptoms. Once the home becomes busy, those assumptions start getting tested.

Maybe PPE is technically available, but staff keep going to another area because the original storage location does not match their workflow. Perhaps hand hygiene products are installed, but staff quickly identify areas where access is less practical than expected. A surveillance process may be well designed, yet information is not consistently reaching the IPAC lead because responsibilities between shifts were never completely clear.

None of these situations automatically mean staff have failed.

Sometimes the system has failed to account for how people actually work.

The first 30 days are therefore a good opportunity to watch, ask questions and look for patterns. How are staff moving through the building? Are supplies available where they need them? Is information about new symptoms reaching the appropriate people? Are staff comfortable initiating Additional Precautions when needed? Are environmental services and nursing workflows supporting each other? Are staff using the processes they were taught during orientation, or have workarounds already started appearing?

Best practice recommends that LTC IPAC programs maintain syndromic surveillance and identify both outcome and performance measures that should be monitored. It also recommends that education continue when specific issues or problems are identified rather than assuming orientation alone is enough.

That distinction matters. Staff orientation tells us what we taught. The first month tells us what people can actually apply.

Days 30 to 60: stop fixing symptoms and start looking for causes

Once the home has been operating for several weeks, patterns usually become easier to see. This is where audits and observations become especially valuable, not because we want to catch people doing something wrong, but because we need an honest picture of where the IPAC system is holding up and where it is struggling.

One of the easiest mistakes to make at this stage is to respond to every gap with more education.

Hand hygiene practice is inconsistent? Re-educate staff.

PPE is not being used appropriately? Re-educate staff.

Environmental cleaning practices vary? Re-educate staff.

Sometimes that is the correct response, but sometimes it is not. If we continue seeing the same problem after education has already been provided, we need to become more curious about what is actually happening.

Is this a knowledge issue? Is the expected process clear? Do staff have access to the right supplies? Is there an unrealistic workflow? Are two departments operating from different expectations? Are leaders reinforcing the same message? Has a workaround developed because the original process is inconvenient?

Auditing becomes much more useful when it helps us answer those questions.

Best practice describes audit and feedback as part of improving practices such as hand hygiene and environmental cleaning. Current Ontario requirements also make auditing an explicit responsibility within the LTC IPAC program and require improvements to be implemented when gaps are identified.

That means the purpose of an audit cannot simply be to produce a compliance percentage. The more important question is what we are going to do with the information.

If several staff members are struggling with the same practice, that should trigger a different conversation than one individual misunderstanding a policy. The first situation may point to a system problem. The second may require individual education or coaching. Treating both situations the same way can result in repeated education without ever addressing the reason the problem keeps coming back.

The IPAC lead cannot stabilize a new home alone

This is also the point where leadership involvement becomes critical.

There can be a tendency during opening to funnel anything infection control-related directly toward the IPAC lead. A new staff member has a question about PPE; send it to IPAC. There is uncertainty about a cleaning process; send it to IPAC. A surveillance issue develops; send it to IPAC. Someone notices a supply problem; send it to IPAC.

Very quickly, the IPAC lead becomes the place where dozens of operational problems accumulate.

That is not a sustainable IPAC program.

Ontario’s regulatory structure recognizes this by requiring an interdisciplinary approach to IPAC and an interdisciplinary team that includes the IPAC lead, Medical Director, Director of Nursing and Personal Care and Administrator. The message behind that structure is important. Infection prevention is not something the IPAC lead performs on behalf of the rest of the home.

The IPAC lead should provide expertise, surveillance, education, oversight and leadership, but many of the solutions require other departments to act. If PPE access is a recurring problem, operations and supply processes may need to change. If environmental cleaning practices are inconsistent, environmental services leadership needs to be part of the solution. If information about symptomatic residents is not consistently being communicated, nursing workflows and accountability may need review.

I have supported new long-term care homes during opening preparation and early operations, and this is one of the reasons I see the post-opening period as more than an IPAC responsibility. Once residents arrive, infection prevention becomes intertwined with almost every part of the home’s operations. The stronger the partnership between IPAC and operational leadership, the easier it becomes to address the cause of a problem rather than simply managing the consequences.

Days 60 to 90: move from opening mode to a sustainable system

By the second and third month, the goal should gradually shift.

During opening, everyone is operating with heightened attention. Leaders are highly visible, additional resources may be available, and staff know that they are working through a major transition. That level of intensity cannot continue forever.

The question becomes whether the systems created during opening can function when the home begins settling into normal operations.

Surveillance is a good example. Public Health Ontario recommends that the IPAC program maintain syndromic surveillance for residents and monitor relevant outcome and performance measures. Ontario regulation separately assigns regular infectious disease surveillance to the IPAC lead. Early in the opening process, it may be possible to chase down missing information manually because everyone is watching the system closely. That does not mean the surveillance process is sustainable.

By this stage, I would want to know whether the information is arriving reliably without constant intervention. Are staff consistently recognizing and reporting symptoms? Can the IPAC lead identify trends? Is there a process for acting on surveillance findings? Are concerns being communicated to leadership and other departments when action is required?

The same test can be applied to auditing. Are audits happening because there was a major opening push, or are they becoming part of regular practice? When an issue is identified, is someone responsible for following up? Is the same deficiency appearing repeatedly? Are audit results being used to adjust education, workflows or resources?

Education should also be shifting from broad opening orientation toward more targeted reinforcement. PHO recommends education upon hire and annually, but also identifies additional education as appropriate when problems are found, policies change, or outbreaks occur. In other words, a good education program responds to what is happening in the home.

By the end of the stabilization period, I would not expect a new home to be perfect. I would expect it to understand itself much better.

Outbreak readiness has to work outside the binder

There is one area where I would be particularly uncomfortable waiting until the home experiences its first outbreak to discover whether the process works.

A written outbreak plan is necessary, but outbreak readiness is much more than having the document available.

Staff need to know how concerns are escalated. The IPAC lead needs access to the information required to identify a potential cluster. Leadership needs to understand its role. PPE and other supplies need to be available. Communication processes need to exist for residents, families and staff. There should also be clarity about how the home will work with its local public health unit when an outbreak is suspected or declared.

Ontario requires the IPAC lead to convene the Outbreak Management Team at the outset of an outbreak and throughout the outbreak as appropriate. Provincial outbreak guidance also identifies routine auditing, staff education, surveillance review, outbreak policies and the availability of PPE and hand hygiene supplies as important parts of preparedness.

This is another reason the first few months matter so much. A new home should not wait for an outbreak to reveal that important phone numbers are difficult to find, staff are unclear about reporting responsibilities or the process for activating the Outbreak Management Team has never really been tested.

Readiness becomes much more meaningful when we walk through these processes before we desperately need them.

By day 90, leaders should have better questions, not just completed checklists

I would be cautious about telling any leader that a new LTC home should be fully stabilized by day 90. Homes differ in size, staffing, resident population, opening approach and operational complexity. Some challenges will emerge immediately, while others may not become visible for several months.

The value of a 90-day framework is not the deadline.

The value is the discipline of deliberately moving from observation, to correction, to sustainability.

By the end of that period, leadership should have a much clearer picture of the IPAC program than it had on opening day. It should understand which processes are working reliably, where staff continue to struggle, which issues are caused by knowledge gaps and which are rooted in workflow or resources. Leaders should know whether surveillance information is useful, whether audits are leading to action, whether staff have the support they need and whether the IPAC lead has the capacity and organizational backing to maintain the program.

There will still be work to do. In fact, there should always be work to do because infection prevention is not a program that reaches a final state and stops changing.

Opening day is just the beginning. The first 90 days are about learning what works, addressing gaps, and making infection prevention part of everyday care.