• National Standard 3 - Preventing and Controlling Healthcare Associated Infections for Dental Services

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  • Conducted by Marrianne Beaty (DHSV Oral Health National Standards Advisor)

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Standard 3 - Audit Report

Criterion 1 - Governance and systems for infection prevention, control and surveillance

  • 3.1.1 A risk management approach is taken in policies, procedures and/or protocols and implemented for: <br>• standard infection control precautions <br>• transmission based precautions<br>• aseptic technique<br>• safe handling and disposal of sharps <br>• prevention and management of occupational exposure to blood and body substances<br>• environmental cleaning and disinfection<br>• antimicrobial prescribing<br>• outbreaks or unusual clusters of communicable infection<br>• processing of reusable medical devices<br>• single-use devices<br>• surveillance and reporting of data where relevant <br>• reporting of communicable and notifiable diseases<br>• provision of risk assessment guidelines to workforce<br>• exposure-prone procedures

  • 3.1.2 The use of policies, procedures and/or protocols is regularly monitored

  • 3.1.3 The effectiveness of the infection prevention and control systems is regularly reviewed at the highest level of governance in the organization

  • 3.1.4 Action is taken to improve the effectiveness of infection prevention and control policies, procedures and/ or protocols (Developmental)

  • 3.2.1 Surveillance systems for healthcare associated infections are in place

  • 3.2.2 Healthcare associated infection surveillance data is regularly monitored by the delegated workforce and/or committees

  • 3.3.1 Mechanisms to regularly assess the healthcare associated infection risks are in place

  • 3.3.2 Action is taken to reduce the risks of healthcare associated infection

  • 3.4.1 Quality improvement activities are implemented to reduce and prevent healthcare associated infections (Developmental)

  • 3.4.2 Compliance with changes in practice are monitored (Developmental)

  • 3.4.3 The effectiveness of changes to practice are evaluated (Developmental)

Criterion 2 - Infection prevention and control strategies

  • 3.5.1 Workforce compliance with current national hand hygiene guidelines is regularly audited

  • 3.5.2 Compliance rates from hand hygiene audits are regularly reported to the highest level of governance in the organization

  • 3.5.3 Action is taken to address non-compliance, or the inability to comply, with the requirements of the current national hand hygiene guidelines

  • 3.6.1 A workforce immunization program that complies with current national guidelines is in use

  • 3.7.1 Infection prevention and control consultation related to occupational health and safety policies, procedures and/or protocols are implemented to address:<br>• communicable disease status<br>• occupational management and prophylaxis <br>• work restrictions<br>• personal protective equipment<br>• assessment of risk to healthcare workers for occupational allergies<br>• evaluation of new products and procedures

  • 3.8.1 Compliance with the system for the use and management of invasive devices is monitored

  • 3.9.1 Education and competency-based training in invasive devices protocols and use is provided for the workforce who perform procedures with invasive devices (Developmental)

  • 3.10.1 The clinical workforce is trained in aseptic technique (Developmental)

  • 3.10.2 Compliance with aseptic technique is regularly audited (Developmental)

  • 3.10.3 Action is taken to increase compliance with the aseptic technique protocols (Developmental)

Criterion 3 - Managing patients with infections or colonizations

  • 3.11.1 Standard precautions and transmission-based precautions consistent with the current national guidelines are in use

  • 3.11.2 Compliance with standard precautions is monitored

  • 3.11.3 Action is taken to improve compliance with standard precautions

  • 3.11.4 Compliance with transmission-based precautions is monitored

  • 3.11.5 Action is taken to improve compliance with transmission‑based precautions

  • 3.12.1 A risk analysis is undertaken to consider the need for transmission-based precautions including:<br>• accommodation based on the mode of transmission (Developmental)<br>• environmental controls through air flow<br>• transportation within and outside the facility<br>• cleaning procedures<br>• equipment requirements

  • 3.13.1 Mechanisms are in use for checking for pre-existing healthcare associated infections or communicable disease on presentation for care

  • 3.13.2 A process for communicating a patient’s infectious status is in place whenever responsibility for care is transferred between service providers or facilities

Criterion 4 - Antimicrobial stewardship

  • 3.14.1 An antimicrobial stewardship program is in place

  • 3.14.2 The clinical workforce prescribing antimicrobials have access to current endorsed therapeutic guidelines on antibiotic usage

  • 3.14.3 Monitoring of antimicrobial usage and resistance is undertaken (not applicable for dental practices)

  • 3.14.4 Action is taken to improve the effectiveness of antimicrobial stewardship

Criterion 5 - Cleaning, disinfection and sterilization

  • 3.15.1 Policies, procedures or protocols for environmental cleaning that address the principles of infection prevention and control are implemented, including:<br>• maintenance of building facilities<br>• cleaning resources and services<br>• risk assessment (undertaken as part of 3.1.1) for cleaning and disinfection based on transmission based precautions and the infectious agent involved <br>• waste management within the clinical environment<br>• laundry and linen transportation, cleaning and storage

  • 3.15.2 Policies, procedures and/or protocols for environmental cleaning are regularly reviewed

  • 3.15.3 An established environmental cleaning schedule is in place and environmental cleaning audits are undertaken regularly

  • 3.16.1 Compliance with relevant national or international standards and manufacturer’s instructions for cleaning, disinfection and sterilization of reusable instruments and devices is regularly monitored

  • 3.17.1 A traceability system that identifies patients who have a procedure using sterile reusable medical instruments and devices is in place

  • 3.18.1 Action is taken to maximize coverage of the relevant workforce trained in a competency based program to decontaminate reusable medical devices (Developmental)

Criterion 6 - Communicating with patients and carers

  • 3.19.1 Information on the organization’s corporate and clinical infection risks and initiatives implemented to minimize patient infection risks is provided to patients and/or carers

  • 3.19.2 Patient infection prevention and control information is evaluated to determine if it meets the needs of the target audience (Developmental)

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