NSQHSS 3

Department

Personnel

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

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

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

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

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

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