A Self-Assessment Guide for Health Care Organizations - IFC

Standard QMI.3 [Infection control]
There is a designated coordination mechanism for all infection control activities that involves physicians, nurses, and others as
appropriate to the size and complexity of the organization.
Intent of QMI.3
Infection prevention and control activities reach into every part of a health care organization and involve individuals in multiple departments
and services, e.g. in clinical departments, facility maintenance, food services, house-keeping, laboratory, pharmacy and sterilization services.
There is a designated mechanism to coordinate the overall Infection Control program. That mechanism may involve a small working group,
or a coordinating committee. Responsibilities include, for example, setting criteria to define health care–associated infections, establishing
data collection and surveillance methods, designing strategies to address infection prevention and control risks, and reporting processes.
Coordination involves communicating with all parts of the organization to ensure that the program is continuous and proactive. Whatever
the mechanism chosen by the organization to coordinate the infection control program, physicians and nurses are represented and engaged
in the activities with the infection control professionals. Others may be included as determined by the organization’s size and complexity
of services (e.g. epidemiologist, data collection expert, statistician, central sterilization manager, microbiologist, pharmacist, housekeeping
services manager, environmental or facilities services manager, operating theater supervisor).
Measurable Element Look for Score Observations
What is required
1) There is a designated
mechanism for the
coordination of the
infection control program
that is based on current
scientific knowledge,
practice guidelines, and
laws/regulations.
How is this element
assessed
A staff member is assigned to
oversee the infection control
program. This may be a full time
post or an assigned role. Their job
description includes this
responsibility. The terms of
reference for an Infection Control
Committee describes the roles and
responsibilities of various staff
members in the program.
The organization has policies and
procedures to ensure that all
aspects of the infection control
program are comprehensively
addressed. Process controls, physical
infrastructure and other regulatory
aspects are adequately addressed.
0 5 10 Why did you give this score
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2) The organization’s
leaders allocate adequate
resources for the infection
control program.
Observation of the facility and
discussions with staff reveal that
there are sufficient supplies,
equipment and human resources
necessary to carry out the infection
control program.
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44 IFC Self-Assessment Guide for Health Care Organizations