Standard 3 - Audit Report

CLINICAL GOVERNANCE AND QUALITY IMPROVEMENT TO PREVENT AND CONTROL HEALTHCARE-ASSOCIATED INFECTIONS AND SUPPORT ANTIMICROBIAL STEWARDSHIP
Integrating clinical governance

3.1 The workforce uses the safety and quality systems from the Clinical Governance Standard when:
a. Implementing policies and procedures for healthcare-associated infections and antimicrobial stewardship
b. Managing risks associated with healthcare-associated infections and antimicrobial stewardship
c. Identifying training requirements for preventing and controlling healthcare-associated infections, and antimicrobial stewardship

Applying quality improvement systems

3.2 The health service organisation applies the quality improvement system from the Clinical Governance Standard when:
a. Monitoring the performance of systems for prevention and control of healthcare-associated infections, and the effectiveness of the antimicrobial stewardship program
b. Implementing strategies to improve outcomes and associated processes of systems for prevention and control of healthcare-associated infections, and antimicrobial stewardship
c. Reporting on the outcomes of prevention and control of healthcare-associated infections, and the antimicrobial stewardship program

Partnering with consumers

3.3 Clinicians use organisational processes from the Partnering with Consumers Standard when preventing and managing healthcare-associated infections, and implementing the antimicrobial stewardship
program to:
a. Actively involve patients in their own care
b. Meet the patient’s information needs
c. Share decision-making

Surveillance

3.4 The health service organisation has a surveillance strategy for healthcare-associated infections and antimicrobial use that:
a. Collects data on healthcare-associated infections and antimicrobial use relevant to the size and scope of the organisation
b. Monitors, assesses and uses surveillance data to reduce the risks associated with healthcare-associated infections and support appropriate antimicrobial prescribing
c. Reports surveillance data on healthcare-associated infections and antimicrobial use to the workforce, the governing body, consumers and other relevant groups

INFECTION PREVENTION AND CONROL SYSTEMS
Standard and transmission-based precautions

3.5 The health service organisation has processes to apply standard and transmission-based precautions that are consistent with the current edition of the Australian Guidelines for the Prevention and Control of Infection in Healthcare, and jurisdictional requirements

3.6 Clinicians assess infection risks and use transmission-based precautions based on the risk of transmission of infectious agents, and consider:
a. Patients’ risks, which are evaluated at referral, on admission or on presentation for care, and re-evaluated when clinically required during care
b. Whether a patient has a communicable disease, or an existing or a pre-existing colonisation or infection with organisms of local or national significance
c. Accommodation needs to manage infection risks
d. The need to control the environment
e. Precautions required when the patient is moved within the facility or to external services
f. The need for additional environmental cleaning or disinfection
g. Equipment requirements

3.7 The health service organisation has processes for communicating relevant details of a patient’s infectious status whenever responsibility for care is transferred between clinicians or health service organisations

Hand hygiene

3.8 The health service organisation has a hand hygiene program that:
a. Is consistent with the current National Hand Hygiene Initiative, and jurisdictional requirements
b. Addresses noncompliance or inconsistency with the current National Hand Hygiene Initiative

Aseptic technique

3.9 The health service organisation has processes for aseptic technique that:
a. Identify the procedures where aseptic technique applies
b. Assess the competence of the workforce in performing aseptic technique
c. Provide training to address gaps in competency
d. Monitor compliance with the organisation’s policies on aseptic technique

Invasive medical devices

3.10 The health service organisation has processes for the appropriate use and management of invasive medical devices that are consistent with the current edition of the Australian Guidelines for the Prevention and Control
of Infection in Healthcare

Clean environment

3.11 The health service organisation has processes to maintain a clean and hygienic environment – in line with the current edition of the Australian Guidelines for the Prevention and Control of Infection in Healthcare, and jurisdictional requirements – that:
a. Respond to environmental risks
b. Require cleaning and disinfection in line with recommended cleaning frequencies
c. Include training in the appropriate use of specialised personal protective equipment for the workforce

3.12 The health service organisation has processes to evaluate and respond to infection risks for:
a. New and existing equipment, devices and products used in the organisation
b. Maintaining, repairing and upgrading buildings, equipment, furnishings and fittings
c. Handling, transporting and storing linen

Workforce immunisation

3.13 The health service organisation has a risk-based workforce immunisation program that:
a. Is consistent with the current edition of the Australian Immunisation Handbook
b. Is consistent with jurisdictional requirements for vaccine-preventable diseases
c. Addresses specific risks to the workforce and patients

REPROCESSING OF REUSABLE MEDICAL DEVICES
Reprocessing of reusable devices

3.14 Where reusable equipment, instruments and devices are used, the health service organisation has:
a. Processes for reprocessing that are consistent with relevant national and international standards, in conjunction with manufacturers’ guidelines
b. A traceability process for critical and semi-critical equipment, instruments and devices that is capable of identifying;
• the patient
• the procedure
• the reusable equipment, instruments and devices that were used for the procedure

ANTIMICROBIAL STEWARDSHIP
Antimicrobial stewardship

3.15 The health service organisation has an antimicrobial stewardship program that:
a. Includes an antimicrobial stewardship policy
b. Provides access to, and promotes the use of, current evidence-based Australian therapeutic guidelines and resources on antimicrobial prescribing
c. Has an antimicrobial formulary that includes restriction rules and approval processes
d. Incorporates core elements, recommendations and principles from the current Antimicrobial Stewardship Clinical Care Standard

3.16 The antimicrobial stewardship program will:
a. Review antimicrobial prescribing and use
b. Use surveillance data on antimicrobial resistance and use to support appropriate prescribing
c. Evaluate performance of the program, identify areas for improvement, and take action to improve the appropriateness of antimicrobial prescribing and use
d. Report to clinicians and the governing body regarding
• compliance with the antimicrobial stewardship policy
• antimicrobial use and resistance
• appropriateness of prescribing and compliance with current evidence-based Australian therapeutic guidelines or resources on antimicrobial prescribing

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.