A Self-Assessment Guide for Health Care Organizations - IFC

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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 ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ 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. ........................................................ ........................................................ ........................................................ 44 IFC Self-Assessment Guide for Health Care Organizations
Measurable Element Look for Score Observations What is required 3) The infection control program includes systematic and proactive surveillance activities to determine usual (endemic) rates of infection and outbreaks of infectious diseases. 4) The organization has established the focus of the infection control program to prevent or reduce the incidence of health care–associated infections, e.g: a. respiratory tract infections are included as appropriate to the organization, 37 b. urinary tract infections (UTI) are included as appropriate to the organization, 38 c. intravascular invasive devices are included as appropriate to the organization, 39 d. surgical wounds are included as appropriate to the organization, 40 e. epidemiologically significant diseases and organisms are included as appropriate to the organization and its community, and f. emerging or reemerging infections are included as appropriate to the organization and its community. 41 How is this element assessed The infection control plan or policies/procedures describe the surveillance process. Surveillance data are documented. Hospital-associated infections are routinely monitored, e.g. pneumonia (particularly ventilator associated), UTI, blood stream infections and surgical wound infections. The data are collected and rates of infection graphed. Comparisons are made across time and against regional or international rates. 0 5 10 Why did you give this score ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ ........................................................ 37 Coffin SE, Klompas M, et. al Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infection Control and Hospital Epidemiology. vol. 29, supplement . Available at www.azdhs.gov 38 Lo E, Nicolle L, et.al Strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infection Control and Hospital Epidemiology. vol. 29, supplement 1 39 Marschall J, Mermel LA, et al. (2008) Strategies to prevent central line–associated bloodstream infections in acute care hospitals. Infection Control and Hospital Epidemiology. vol. 29, supplement 1 40 Anderson DJ, Kaye KS, et al. (2008) Strategies to prevent surgical site infections in acute care hospitals. Infection Control and Hospital Epidemiology. vol. 29, supplement 1 41 Dubberke ER, Gerding DN, et al. (2008) Strategies to prevent Clostridium difficile infections in acute care hospitals. Infection Control and Hospital Epidemiology. vol. 29, supplement 1. Available at: www.wvidep.org/Portals/31/infection%20control/SHEA%20Prevent%20C%20dif%20in%20Acute%20Care%20Oct08.pdf IFC Self-Assessment Guide for Health Care Organizations 45
Page 1 and 2: PROMOTING STANDARDS IN THE PRIVATE
Page 3 and 4: Contents Foreword 2 Acknowledgement
Page 5 and 6: Acknowledgements This Guide was dev
Page 7 and 8: introduction IFC Self-Assessment Gu
Page 9 and 10: Why are Standards Important Why sho
Page 11 and 12: Leadership Systems Data Where to Be
Page 13 and 14: Preparing for the self-assessment I
Page 15 and 16: Facility Safety and Emergency Manag
Page 17 and 18: The self -assessment template IFC S
Page 19 and 20: Clinical Governance and Leadership
Page 21 and 22: Measurable Element Look for Score O
Page 25 and 26: Standard CGL.6 [Staff recruitment,
Page 27 and 28: Standard EPR.2 [Patient and family
Page 29 and 30: Standard EPR.3 [Informed consent] P
Page 31 and 32: Standard EPR.4 [Ethical management]
Page 33 and 34: Standard EPR.5 [Organ and tissue do
Page 35 and 36: Standard EPR.6 [Reproductive health
Page 37 and 38: Standard EPR.7 [Termination of preg
Page 41 and 42: Quality Measurement and Improvement
Page 43 and 44: Standard QMI.2 [Leaders’ collabor
Page 45: Measurable Element Look for Score O
Page 51 and 52: Standard QMI.4 [Medications use] Me
Page 57 and 58: Patient Safety (PS) Standard PS.1 [
Page 59 and 60: Standard PS.2 [Effective communicat
Page 61 and 62: Standard PS.4 [Correct site, proced
Page 63 and 64: Standard PS.5 [Health care associat
Page 65 and 66: Facility Safety and Emergency Manag
Page 73 and 74: Standard FSE.6 [Utilities managemen
Page 75 and 76: IFC Self-Assessment Guide for Healt
Page 77 and 78: After the self-assessment Next Step
Page 79 and 80: Baseline Score Score Score Clinical
Page 81 and 82: EPR.6 Reproductive health policies
Page 83 and 84: QMI.4 Medications use 1 Medication
Page 85 and 86: Baseline Score Score Score Facility
Page 87 and 88: STEP 5: Develop an Action Plan The
Page 89 and 90: IFC Self-Assessment Guide for Healt
Page 91 and 92: Appendices IFC Self-Assessment Guid
Page 93 and 94: 11. Organ donation and transplant T
Page 95 and 96: Clinical Privileging Committee The
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emergency 1. An unanticipated or su
Page 99 and 100:
privileging The process whereby a s
Page 102:
Contact Information Health and Educ
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A Self-Assessment Guide for Health Care Organizations - IFC

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