• Document No.

  • Department

  • Conducted on

  • Prepared by

  • Personnel

Governance and systems for infection prevention, control and surveillance

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

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

  • 3.2.1 Surveillance systems for healthcare associated infections are in plac

  • 3.2.1 HAI data are regularly monitored by the delegated workforce and/or committees

  • 3.3.1 Mechanisms to regularly assess the HAI risks are in place

  • 3.3.2 Action is taken to reduce the risks of HAI

  • 3.4.1 Quality improvment activities are implemented to reduce and prevent HAI

  • 3.4.2 Compliance with changes in practice are monitored

  • 3.4.3 (D) The effectiveness of changes in practice are monitored

Infection prevetion 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 organisation

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

  • 3.6.1 A workforce immunisation 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 being implemented to address:  communicable disease status  occupational management and prophylaxis  work restrictions  personal protective equipment  assessment of risk to healthcare workers for occupational allergy  evaluation of new products and procedures

  • 3.8.1 Compliance with the system for the use and management of invasive device 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

  • 3.10.1 The clinical workforce is training in aseptic non-touch technique

  • 3.10.2 Compliance with aseptic non-touch technique is regularly audited

  • 3.10.3 Action is taken to increase compliance with aseptic non-touch technique

Managing Patient with infections or colonisations

  • 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:  accommodation based on the mode of transmission  environmental controls through air flow  transportation within and outside the facility  cleaning procedures  equipment requirements

  • 3.13.1 Mechanisms are in use to check for pre-existing healthcare associated infection or communicable disease on presentation for care

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

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

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

Cleaning, disinfection and sterilisation

  • 3.15.1 Policies, procedures and/or protocols for environmental cleaning that address the principles of infection prevention and control are implemented, including:  maintenance of building facilities  cleaning resources and services  risk assessment for cleaning and disinfection based on transmission- based precautions and the infectious agent involved  waste management within the clinical environment  laundry and linen transportation, cleaning and storage  appropriate use of personal protective equipment

  • 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 sterilisation 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 maximise coverage of the relevant workforce trained in a competency-based program to decontaminate reusable medical devices

Communicating with patients and carers

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

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

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