Action 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

Intent

Safety and quality systems support clinicians in preventing and controlling healthcare-associated infections, and antimicrobial stewardship.

Reflective questions

How are the health service organisation’s safety and quality systems used to:

  • Support implementation of policies and procedures to minimise healthcare-associated infections
  • Identify and manage risks associated with healthcare-associated infections
  • Identify training requirements to prevent and control healthcare-associated infections, and improve antimicrobial stewardship?

Key tasks

  • Set up and implement governance structures for healthcare-associated infections and antimicrobial stewardship.

  • Develop and implement policies and procedures for healthcare-associated infections and antimicrobial stewardship.

  • Use organisation-wide risk management systems to identify, monitor, manage and review risks associated with healthcare-associated infections and antimicrobial stewardship.

  • Deliver or provide access to training on healthcare-associated infections and antimicrobial stewardship based on the specific needs of the clinical workforce.

Strategies for improvement

Hospitals

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

Action 1.7 – policies and procedures

Action 1.10 – risk management systems

Actions 1.19, 1.20 and 1.21 – education and training

Health service organisations should:

  • Use these and other established safety and quality systems to support policies and procedures, risk management and training for healthcare-associated infections and antimicrobial stewardship.

  • Ensure that current versions of all relevant policies and procedures are readily available and accessible to clinicians.

Policies may be developed or adapted at different levels within the organisation. However, all policy documents should be incorporated into a single coherent set to maximise the effectiveness of the policy development process.

Implement policies and procedures

Ensure that current, readily available and accessible organisational policies and procedures are in place that cover priority areas for infection prevention and control, and antimicrobial stewardship, in the organisation, including:

  • Standard and transmission-based precautions

  • Environmental cleaning and disinfection

  • Reprocessing of reusable medical devices

  • Single-use items

  • Insertion and maintenance of invasive devices

  • Outbreaks or unusual clusters of infection or communicable disease

  • Reporting requirements for communicable and notifiable diseases

  • Antimicrobial prescribing and use

  • Safe work practices for

    • use, handling and disposal of sharps

    • waste and linen management

    • workforce immunisation

    • exposure-prone procedures

    • prevention and management of occupational exposures to blood and body substances

  • Product management and evaluation of new and existing products, equipment and devices

  • Preventive maintenance including repairs, refurbishment and upgrade of infrastructure, including buildings, equipment, fixtures and fittings.

Manage risks

Use established risk management systems (see Action 1.10) to identify, monitor, manage and review risks associated with preventing and controlling healthcare-associated infections. Develop processes to manage clinical risks for different populations served within the organisation, clinical and workplace risks for the workforce, and organisational risks.

Use information from measurement and quality improvement systems, adverse events, clinical outcomes and patient experiences to inform and update risk assessments and the risk management system. Consider the training the workforce may need to effectively use incident management and investigation systems to inform risk management, and to plan and implement quality improvement processes to mitigate these risks.

Health service organisations should manage the risk of infection and have local risk management strategies in place, regardless of where the governance for the organisation is located.

Identify training requirements

Assess the competency and training needs of the workforce in line with the requirements of Actions 1.19-1.21. Perform a risk assessment to inform the training schedule and set priorities for the members of the workforce who require training. Develop, or provide access to, training and education resources to meet the needs of the workforce regarding infection prevention and control activities, reprocessing of reusable medical devices, and antimicrobial prescribing and use.

Identify the processes used in the health service organisation to manage training requirements for infection prevention and control activities, reprocessing of reusable medical devices, and antimicrobial prescribing and use.

If appropriate, use a competency-based assessment process that is aligned with the organisation’s policies, procedures and protocols for hand hygiene, aseptic technique, invasive device insertion and maintenance, putting on and removal of personal protective equipment, reprocessing of reusable medical devices, and environmental cleaning.

Competency-based assessment is the assessment of actual skills and knowledge that a person can demonstrate in the workplace. A workplace assessor reviews the evidence and verifies the person's competence in performing the assessed task.

Review the organisation’s induction, and ongoing education and training programs to ensure that they include relevant information, tools and instructions on infection prevention and control policies and procedures for new and existing employees and contractors.

Develop, review or introduce an appraisal process for the workforce that incorporates:

  • Awareness and understanding of relevant policies, procedures and protocols relating to infection risks in the workplace

  • Use of infection prevention and control policies, procedures and protocols

  • Education, training or competency assessment for relevant risk management processes, and incident management and investigation systems.

Related actions

In addition to these strategies, Actions 3.15 and 3.16 include specific strategies for the implementation, monitoring and evaluation of the organisation’s antimicrobial stewardship program.

Day Procedure Services

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

Action 1.7 – policies and procedures

Action 1.10 – risk management systems

Actions 1.19, 1.20 and 1.21 – education and training

Health service organisations should:

  • Use these and other established safety and quality systems to support policies and procedures, risk management and training for healthcare-associated infections and antimicrobial stewardship
     
  • Ensure that current versions of all relevant policies and procedures are readily available and accessible to clinicians.

Policies may be developed or adapted at different levels within the organisation.

However, all policy documents should be incorporated into a single, coherent set to maximise the effectiveness of the policy development process.

Implement policies and procedures

Ensure that current, readily available and accessible organisational policies and procedures are in place that cover priority areas for infection prevention and control, and antimicrobial stewardship, in the organisation, including:

  • Standard and transmission-based precautions
  • Environmental cleaning and disinfection
  • Reprocessing of reusable medical devices
  • Single-use items
  • Insertion and maintenance of invasive devices
  • Outbreaks or unusual clusters of infection or communicable disease
  • Reporting requirements for communicable and notifiable diseases
  • Antimicrobial prescribing and use
  • Safe work practices for
    • use, handling and disposal of sharps
    • waste and linen management
    • workforce immunisation
    • exposure-prone procedures
    • prevention and management of occupational exposures to blood and body substances
  • Product management and evaluation of new and existing products, equipment and devices
  • Preventive maintenance, including repairs, refurbishment and upgrade of infrastructure, including buildings, equipment, fixtures and fittings.

These policies, procedures and protocols may be developed by the individual service or the corporate group.

Manage risks

Use established risk management systems (see Action 1.10) to identify, monitor, manage and review risks associated with preventing and controlling healthcare-associated infections. Develop processes to manage clinical risks for different populations served within the organisation, clinical and workplace risks for the workforce, and organisational risks.

Use information from measurement and quality improvement systems, adverse events, clinical outcomes and patient experiences to inform and update risk assessments and the risk management system. Consider the training the workforce may need to effectively use incident management and investigation systems to inform risk management, and to plan and implement quality improvement processes to mitigate these risks.

Day procedure services should manage the risk of infection and have local risk management strategies in place, regardless of where the governance for the service is located.

Identify training requirements

Assess the competency and training needs of the workforce in line with the requirements of Actions 1.19–1.21. Perform a risk assessment to inform the training schedule and set priorities for the members of the workforce who require training. Develop, or provide access to, training and education resources to meet the needs of the workforce regarding infection prevention and control activities, reprocessing of reusable medical devices, and antimicrobial prescribing and use.

Identify the processes used in the health service organisation to manage training requirements for infection prevention and control activities, reprocessing of reusable medical devices, and antimicrobial prescribing and use.

If appropriate, use a competency-based assessment process that is aligned with the organisation’s policies, procedures and protocols for hand hygiene, aseptic technique, invasive device insertion and maintenance, putting on and removal of personal protective equipment, reprocessing of reusable medical devices, and environmental cleaning.

Competency-based assessment is the assessment of actual skills and knowledge that a person can show in the workplace. A workplace assessor reviews the evidence and verifies the person’s competence in performing the assessed task.

Review the organisation’s induction, and ongoing education and training programs to ensure that they include relevant information, tools and instructions on infection prevention and control policies and procedures for new and existing employees and contractors.

Develop, review or introduce an appraisal process for the workforce that incorporates:

  • Awareness and understanding of relevant policies, procedures and protocols relating to infection risks in the workplace
  • Use of infection prevention and control policies, procedures and protocols
  • Education, training or competency assessment for relevant risk management processes, and incident management and investigation systems for infection prevention.

Related actions

In addition to these strategies, Actions 3.15 and 3.16 include specific strategies for the implementation, monitoring and evaluation of the organisation’s antimicrobial stewardship program.

Examples of evidence

Select only examples currently in use:

  • Policy documents about infection prevention and control that include risk assessment and risk management strategies, and instructions for clinicians
  • Audit results of workforce compliance with policies and procedures for infection prevention and control, and antimicrobial stewardship
  • Surveillance data that are used to improve infection prevention and control
  • Action plan based on the risk assessment of the health service organisation’s infection prevention and control systems
  • Training documents about the health service organisation’s infection prevention and control systems.
MPS & Small Hospitals

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

Health service organisations should:

  • Use these and other established safety and quality systems to support policies and procedures, risk management and training for healthcare-associated infections and antimicrobial stewardship
  • Ensure that current versions of all relevant policies and procedures are readily available and accessible to clinicians.

Policies may be developed or adapted at different levels within the organisation. However, all policy documents should be incorporated into a single, coherent set to maximise the effectiveness of the policy development process.

Implement policies and procedures

Ensure that current, readily available and accessible organisational policies and procedures are in place that cover priority areas for infection prevention and control, and antimicrobial stewardship, in the organisation, including:

  • Standard and transmission-based precautions
  • Environmental cleaning and disinfection
  • Reprocessing of reusable medical devices
  • Single-use items
  • Insertion and maintenance of invasive devices
  • Outbreaks or unusual clusters of infection or communicable disease
  • Reporting requirements for communicable and notifiable diseases
  • Antimicrobial prescribing and use
  • Safe work practices for
    • use, handling and disposal of sharps
    • waste and linen management
    • workforce immunisation
    • exposure-prone procedures
    • prevention and management of occupational exposures to blood and body substances
  • Product management and evaluation of new and existing products, equipment and devices
  • Preventive maintenance, including repairs, refurbishment and upgrade of infrastructure, including buildings, equipment, fixtures and fittings.

Manage risks

Use established risk management systems (see Action 1.10) to identify, monitor, manage and review risks associated with preventing and controlling healthcare-associated infections. Develop processes to manage clinical risks for different populations served within the organisation, clinical and workplace risks for the workforce, and organisational risks.

Use information from measurement and quality improvement systems, adverse events, clinical outcomes and patient experiences to inform and update risk assessments and the risk management system. Consider the training the workforce may need to effectively use incident management and investigation systems to inform risk management, and to plan and implement quality improvement processes to mitigate these risks.

Health service organisations should manage the risk of infection and have a local risk management plan in place, regardless of where the governance for the organisation is located.

Identify training requirements

Assess the competency and training needs of the workforce in line with the requirements of Actions 1.19–1.21. Perform a risk assessment to inform the education plan and to set priorities for the members of the workforce who require training. Develop, or provide access to, training and education resources to meet the needs of the workforce regarding infection prevention and control activities, reprocessing of reusable medical devices, and antimicrobial prescribing and use.

Identify the processes used in the health service organisation to manage training requirements for infection prevention and control activities, reprocessing of reusable medical devices, and antimicrobial prescribing and use.

If appropriate, use a competency-based assessment process that is aligned with the organisation’s policies, procedures and protocols for hand hygiene, aseptic technique, invasive device insertion and maintenance, putting on and removal of personal protective equipment, reprocessing of reusable medical devices, and environmental cleaning.

Competency-based assessment is the assessment of actual skills and knowledge that a person can show in the workplace. A workplace assessor reviews the evidence and verifies the person’s competence in performing the assessed task.

Review the organisation’s induction, and ongoing education and training programs to ensure that they include relevant information, tools and instructions on infection prevention and control policies and procedures for new and existing employees and contractors.

Develop, review or introduce an appraisal process for the workforce that incorporates:

  • Awareness and understanding of relevant policies, procedures and protocols relating to infection risks in the workplace
  • Use of infection prevention and control policies, procedures and protocols
  • Education, training or competency assessment for relevant risk management processes, and incident management and investigation systems for infection prevention.
Last updated 21st June, 2018 at 07:13pm
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