Trust Board Febuary 2010 - Sandwell & West Birmingham Hospitals
Trust Board Febuary 2010 - Sandwell & West Birmingham Hospitals
Trust Board Febuary 2010 - Sandwell & West Birmingham Hospitals
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SWBTB (2/10) 046 (a)<br />
Compliance Criteria Outcome required Action required/to have in place Who<br />
By/Exec<br />
Lead<br />
1<br />
Have in place and<br />
operate effective<br />
management systems<br />
for the prevention and<br />
control of HCAI which<br />
are informed by risk<br />
assessments and<br />
analysis of infection<br />
incidents<br />
1a<br />
1b<br />
A <strong>Board</strong> level agreement outlining the boards<br />
collective responsibility for minimizing the<br />
risks of infection and the general means by<br />
when it prevents and controls such risks.<br />
The designation of an individual as Director<br />
of Infection Prevention and Control,<br />
accountable to the Chief Executive and the<br />
<strong>Board</strong>.<br />
• <strong>Board</strong> level agreement<br />
• Risk assessment and incorporation of risks<br />
into the <strong>Trust</strong> Risk Register<br />
• System of risk and incident reporting and<br />
investigation<br />
• Appropriate structures in place for<br />
managing risk.<br />
• Appoint a DIPC<br />
• Provide system for reporting to TB<br />
Chief Nurse<br />
Chief<br />
Executive<br />
Status<br />
Green<br />
Green<br />
Overall Status:<br />
‘MEETS’<br />
1c<br />
1d<br />
A mechanism that ensures sufficient<br />
resources are available to secure the<br />
effective prevention and control of HCAIs.<br />
Ensuring that relevant staff, contractors and<br />
others who are directly or indirectly<br />
concerned with patient care receive suitable<br />
and sufficient information on infection<br />
prevention and control.<br />
• <strong>Trust</strong> Assurance Framework<br />
• Infection Control Action Plan<br />
• Infection Control Programme<br />
• Infection Control team and information<br />
infrastructure<br />
• Infection Control Operational Committee<br />
and Executive Committee<br />
• Training programmes for all staff and<br />
evidence of attendance.<br />
• Specific induction for contractors.<br />
Chief Nurse<br />
Director of<br />
Workforce<br />
Green<br />
Green<br />
1e<br />
1f<br />
A programme of audit to ensure key policies<br />
and practices are being implemented<br />
appropriately.<br />
A policy addressing the admission,<br />
discharge, transfer and movement of patients<br />
between departments and health care<br />
facilities.<br />
• Develop a programme of audit against all<br />
key policies<br />
• Identify resources and timescales<br />
• Identify reporting cycle<br />
• Develop an all encompassing bed<br />
management policy<br />
• Develop and deliver relevant training and<br />
awareness raising<br />
DIPC<br />
Chief<br />
Operating<br />
Officer<br />
Green<br />
Green<br />
Infection Control <strong>Trust</strong> <strong>Board</strong> Assurance Framework Feb <strong>2010</strong> V12 2 of 6
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