Action 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

Intent

Quality-improvement systems are used to support the prevention and control of healthcare-associated infections, and improvements in the antimicrobial stewardship program.

Reflective questions

How are the systems for prevention and control of healthcare-associated infections, and the effectiveness of the antimicrobial stewardship program continuously evaluated and improved?

How are the outcomes of improvement activities reported to the governing body, the workforce, consumers and other organisations?

Key tasks

  • Review, measure and assess the effectiveness and performance of organisational and clinical strategies for the prevention and control of healthcare-associated infections, and antimicrobial stewardship.

  • Implement quality improvement strategies for healthcare-associated infections and antimicrobial stewardship based on the outcomes of monitoring activities.

  • Provide information on the outcomes of quality improvement activities to the governing body, the workforce, consumers and other organisations.

Strategies for improvement

Hospitals

The Clinical Governance Standard has specific actions relating to health service organisations’ quality improvement systems:

Action 1.8 – quality improvement systems

Action 1.9 – reporting

Action 1.11 – incident management and investigation systems

Health service organisations should use these and other established safety and quality systems to support monitoring, reporting and implementation of quality improvement strategies for healthcare-associated infections and antimicrobial stewardship.

Monitor effectiveness and performance

Use the organisation’s quality improvement systems to identify, and set priorities for, organisational and clinical strategies to prevent healthcare-associated infections and manage the risks.

Review these systems to ensure that they include requirements for:

  • Using the organisation’s incident management and investigation system to identify and improve safety and quality activities
  • Measuring performance and identifying opportunities for improvement
  • Reporting outcomes to the organisation’s leadership, workforce, consumers and (if appropriate) other health service organisations
  • Engaging with consumers to review the performance of safety and quality activities
  • Communicating the outcomes of quality improvement activities in newsletters and publications
  • Maintaining and improving the effectiveness of the antimicrobial stewardship program.

Identify the key elements of an antimicrobial stewardship program that will both show performance and inform prescribing practice and use of antimicrobials in the organisation.

Identify how the organisation will evaluate compliance with policies, procedures and protocols relating to infection prevention and control, and antimicrobial stewardship (including hand hygiene, aseptic technique, invasive device insertion and maintenance, infection surveillance, environmental cleaning, workforce immunisation, standard and transmission-based precautions, reprocessing of reusable medical devices, and antimicrobial prescribing and use).

Review the results of annual evaluation of the organisation’s quality improvement program for infection prevention and control, to acknowledge successes and identify opportunities for improvement.

Implement quality improvement strategies

Use the results of monitoring activities to show improvements or areas where improvement is required. Where appropriate, use quality improvement activities that are consistent and measurable across the corporate group, network or health service.

Use the results of the organisational risk assessment to identify gaps, plan, and set priorities for areas for investigation or action.

Identify where the organisation is performing well, including where infection risks have been minimised or eliminated.

Report outcomes

Report evaluation findings to the governing body and the workforce. Use the data to work with consumers, the workforce, clinical leaders and managers to identify and implement improvements.

Related actions

In addition to these strategies:

  • Action 3.4 outlines surveillance strategies to support infection prevention and control activities, and the antimicrobial stewardship program; these strategies can be used to identify gaps and set priorities for actions to minimise risk in the prevention and control of healthcare-associated infections, and antimicrobial stewardship
  • Action 3.16 includes specific strategies for ongoing monitoring, evaluation and improvement activities for the organisation’s antimicrobial stewardship program.
Day Procedure Services

The Clinical Governance Standard has specific actions relating to health service organisations’ quality improvement systems.

Action 1.8 – quality improvement systems

Action 1.9 – reporting

Action 1.11 – incident management and investigation systems

Health service organisations should use these and other established safety and quality systems to support monitoring, reporting and implementation of quality improvement strategies for healthcare associated infections and antimicrobial stewardship.

Monitor effectiveness and performance

Use the organisation’s quality improvement systems to identify, and set priorities for, organisational and clinical strategies to prevent healthcare-associated infections and manage the risks.

Review these systems to ensure that they include requirements for:

  • Using the organisation’s incident management and investigation system to identify and improve safety and quality activities
  • Measuring performance and identifying opportunities for improvement
  • Reporting outcomes to the organisation’s leadership, workforce, consumers and (if appropriate) other health service organisations
  • Engaging with consumers to review the performance of safety and quality activities
  • Communicating the outcomes of quality improvement activities in newsletters and publications
  • Maintaining and improving the effectiveness of the antimicrobial stewardship program.

Identify the key elements of an antimicrobial stewardship program that will both show performance and inform prescribing practice and use of antimicrobials in the organisation.

Identify how the organisation will evaluate compliance with policies, procedures and protocols relating to infection prevention and control, and antimicrobial stewardship (including hand hygiene, aseptic technique, invasive device insertion and maintenance, infection surveillance, environmental cleaning, workforce immunisation, standard and transmission-based precautions, reprocessing of reusable medical devices, and antimicrobial prescribing and use).

Review the results of annual evaluation of the organisation’s quality improvement program for infection prevention and control, to acknowledge successes and identify opportunities for improvement.

Implement quality improvement strategies

Use the results of monitoring activities to show improvements or areas where improvement is required. Where appropriate, use quality improvement activities that are consistent and measurable across the corporate group, network or health service.

Use the results of the organisational risk assessment to identify gaps, plan, and set priorities for areas for investigation or action.

Identify where the organisation is performing well, including where infection risks have been minimised or eliminated.

Report outcomes

Report evaluation findings to the governing body and the workforce. Use the data to work with consumers, the workforce, clinical leaders and managers to identify and implement improvements.

Related actions

In addition to these strategies:

  • Action 3.4 outlines surveillance strategies to support infection prevention and control activities, and the antimicrobial stewardship program; these strategies can be used to identify gaps and set priorities for action to minimise risk in the prevention and control of healthcare-associated infections, and antimicrobial stewardship
  • Action 3.16 includes specific strategies for ongoing monitoring, evaluation and improvement activities for the organisation’s antimicrobial stewardship program.

Examples of evidence

Select only examples currently in use:

  • Improvements made to the health service organisation’s infection prevention and control system
  • Reports to the highest level of governance, the workforce and consumers on infection prevention and control outcomes of the health service organisation’s quality improvement program
  • Performance evaluation of the infection prevention and control program by leadership, the workforce and consumers as part of the health service organisation’s quality improvement program
  • Audit results of infection prevention and control activities included in the quality improvement system.
MPS & Small Hospitals

The Clinical Governance Standard has specific actions relating to health service organisations’ quality improvement systems.

Action 1.8 – quality improvement systems

Action 1.9 – reporting

Action 1.11 – incident management and investigation systems

Health service organisations should use these and other established safety and quality systems to support monitoring, reporting and implementation of quality improvement strategies for healthcare associated infections and antimicrobial stewardship.

Monitor effectiveness and performance

Use the organisation’s quality improvement systems to identify, and set priorities for, organisational and clinical strategies to prevent healthcare-associated infections and manage the risks.

Review these systems to ensure that they include requirements for:

  • Using the organisation’s incident management and investigation system to identify and improve safety and quality activities
  • Measuring performance and identifying opportunities for improvement
  • Reporting outcomes to the organisation’s leadership, workforce, consumers and (if appropriate) other health service organisations
  • Engaging with consumers to review the performance of safety and quality activities
  • Communicating the outcomes of quality improvement activities in newsletters and publications
  • Maintaining and improving the effectiveness of the antimicrobial stewardship program.

Identify the key elements of an antimicrobial stewardship program that will both show performance and inform prescribing practice and use of antimicrobials in the organisation.

Identify how the organisation will evaluate compliance with policies, procedures and protocols relating to infection prevention and control, and antimicrobial stewardship (including hand hygiene, aseptic technique, invasive device insertion and maintenance, infection surveillance, environmental cleaning, workforce immunisation, standard and transmission-based precautions, reprocessing of reusable medical devices, and antimicrobial prescribing and use).

Review the results of annual evaluation of the organisation’s quality improvement program for infection prevention and control, to acknowledge successes and identify opportunities for improvement.

Implement quality improvement strategies

Use the results of monitoring activities to show improvements or areas where improvement is required. Where appropriate, use quality improvement activities that are consistent and measurable across the corporate group, network or health service.

Use the results of the organisational risk assessment to identify gaps, plan, and set priorities for areas for investigation or action.

Identify where the organisation is performing well, including where infection risks have been minimised or eliminated.

Report outcomes

Report evaluation findings to the governing body and the workforce. Use the data to work with consumers, the workforce, clinical leaders and managers to identify and implement improvements.

Last updated 2nd July, 2018 at 10:33pm
BACK TO TOP