Action 3.11

The health service organisation has processes to maintain a clean and hygienic environment – in line with the current edition of the Australian Guidelines for the Prevention and Control of Infection in Healthcare, and jurisdictional requirements – that:

a. Respond to environmental risks

b. Require cleaning and disinfection in line with recommended cleaning frequencies

c. Include training in the appropriate use of specialised personal protective equipment for the workforce

Intent

Health service organisations identify and respond to environmental and infection risks by providing a clean environment for patients and the workforce.

Reflective questions

What processes are used to maintain a clean and hygienic environment in line with the current edition of the Australian Guidelines for the Prevention and Control of Infection in Healthcare1 and with state or territory requirements?

How does the health service organisation ensure that the workforce is trained in the appropriate use of specialised personal protective equipment?

Key tasks

  • Identify the environmental cleaning hazards in the organisation and include these in the organisation’s risk management strategies.

  • Review or develop policies, procedures and protocols to include effective strategies to provide a clean environment in the organisation.

  • Use the implementation and evaluation strategies for environmental cleaning to ensure that cleaning and disinfection processes are in line with recommended cleaning frequencies appropriate to the health service organisation.

  • Provide training to the workforce undertaking environmental cleaning activities and include the use of specialised personal protective equipment if required.

  • Evaluate environmental cleaning practices for compliance with policies, procedures and protocols, and measure outcomes of cleaning processes.

  • Review duty lists, position descriptions or contract specifications as part of the appraisal or contract review process, and provide feedback to the relevant person or group on achievements or areas for improvement.

Strategies for improvement

Hospitals

Include environmental cleaning risks in the organisation’s risk management strategies, and ensure that cleaning processes have the support of the governing body and executive.

Implementation strategies for a clean environment should be evidence based and have a risk management focus. Strategies may include:

  • Workforce and contractor education
  • Version control and standardised formats for
    • policies
    • procedures
    • position descriptions
    • duty lists
    • contract specifications (for contracted cleaning services)
  • Processes to assess effectiveness
  • Evaluation of the cleaning program.

The governing body is responsible for overseeing contracted cleaning services. Contract development, documentation and record keeping should include consultation with key groups, including:

  • The cleaning manager
  • Infection prevention and control
  • Corporate services
  • Governance.

Develop cleaning and disinfection schedules that meet the requirements outlined in the Australian Guidelines for the Prevention and Control of Infection in Healthcare1 and relevant state or territory requirements. These schedules should include:

  • Frequency and type of activity
  • Product and equipment to be used
  • Specialised personal protective equipment, if required
  • Safety instructions.

Ensure that position descriptions and duty lists are current, and consistent with the environmental cleaning and disinfection schedules used in the organisation.

Monitor performance

Identify areas that require audit and evaluation of environmental cleaning and disinfection processes, and use audit and evaluation tools that effectively assess compliance with policies, procedures and protocols used in the organisation. Report to the governing body on improvements achieved and areas in which further improvement is needed as part of the quality improvement program.

Include environmental cleaning and a process to deal with any identified issues in the organisation’s incident management and investigation system. Review the incident management and investigation system to identify any incidents relating to environmental cleaning activities and act to prevent incidents recurring.

Day Procedure Services

Include environmental cleaning risks in the organisation’s risk management strategies, and ensure that cleaning processes have the support of the governing body and executive.

Implementation strategies for a clean environment should be evidence based and have a risk management focus. Strategies may include:

  • Workforce and contractor education
  • Version control and standardised formats for
    • policies
    • procedures
    • position descriptions
    • duty lists
    • contract specifications (for contracted cleaning services)
  • Processes to assess effectiveness
  • Evaluation of the cleaning program.

The governing body is responsible for overseeing contracted cleaning services. Contract development, documentation and record keeping should include consultation with key groups, including:

  • The cleaning manager
  • Infection prevention and control
  • Corporate services
  • Governance.

Develop cleaning and disinfection schedules that meet the requirements outlined in the Australian Guidelines for the Prevention and Control of Infection in Healthcare and relevant state or territory requirements. These schedules should include:

  • Frequency and type of activity
  • Products and equipment to be used
  • Specialised personal protective equipment, if required
  • Safety instructions.

Ensure that position descriptions and duty lists are current, and consistent with the environmental cleaning and disinfection schedules used in the organisation.

Monitor performance

Identify areas that require audit and evaluation of environmental cleaning and disinfection processes, and use audit and evaluation tools that effectively assess compliance with policies, procedures and protocols used in the organisation. Report to the governing body on improvements achieved and areas in which further improvement is needed as part of the quality improvement program.

Include environmental cleaning and a process to deal with any identified issues in the organisation’s incident management and investigation system. Review the incident management and investigation system to identify any incidents relating to environmental cleaning activities and act to prevent incidents recurring.

It may be appropriate for some day procedure services to work with the overarching corporate organisation to identify the available resources that can support the environmental cleaning program.

Examples of evidence

Select only examples currently in use:

  • Policy documents about a clean and hygienic environment
  • Cleaning and disinfection schedules that meet the requirements outlined in the Australian Guidelines for the Prevention and Control of Infection in Healthcare and relevant state or territory requirements
  • Audit results of cleaning and disinfection practices
  • Committee and meeting records relating to cleaning and disinfection
  • Contracts with external cleaning providers that outline the health service organisation’s requirements for cleaning and disinfection
  • Results of consumer experience surveys, and actions taken to deal with issues identified regarding cleaning and disinfection
  • Training documents for the workforce about the use of specialised personal protective equipment
  • Audit results of the use of specialised personal protective equipment.
MPS & Small Hospitals

MPSs and small hospitals should:

  • Identify the environmental cleaning hazards in the organisation and include these in the organisation’s risk management strategies
  • Review or develop policies, procedures and protocols to include effective strategies to provide a clean environment in the organisation
  • Use the implementation and evaluation strategies for environmental cleaning to ensure that cleaning and disinfection processes are in line with recommended cleaning frequencies appropriate to the health service organisation
  • Provide training to the workforce performing environmental cleaning activities and include the use of specialised personal protective equipment, if required
  • Evaluate environmental cleaning practices for compliance with policies, procedures and protocols, and measure outcomes of cleaning processes
  • Review duty lists, position descriptions or contract specifications as part of the appraisal or contract review process, and provide feedback to the relevant person or group on achievements or areas for improvement.

Develop cleaning and disinfection schedules that meet the requirements outlined in the Australian Guidelines for the Prevention and Control of Infection in Healthcare and relevant state or territory requirements. These schedules should include:

  • Frequency and type of activity
  • Products and equipment to be used
  • Specialised personal protective equipment, if required
  • Safety instructions.

Ensure that position descriptions and duty lists are current, and consistent with the environmental cleaning and disinfection schedules used in the organisation.

Monitor performance

Identify areas that require audit and evaluation of environmental cleaning and disinfection processes, and use audit and evaluation tools that effectively assess compliance with policies, procedures and protocols used in the organisation. Report to the governing body on improvements and areas in which further improvement is needed as part of the quality improvement program.

Include environmental cleaning and a process to deal with any identified issues in the organisation’s incident management and investigation system. Review the incident management and investigation system to identify any incidents relating to environmental cleaning activities and act to prevent incidents recurring.

Action 3.12

The health service organisation has processes to evaluate and respond to infection risks for:

a. New and existing equipment, devices and products used in the organisation

b. Maintaining, repairing and upgrading buildings, equipment, furnishings and fittings

c. Handling, transporting and storing linen

Intent

The health service organisation minimises infection risks to patients and the workforce from equipment, device, product and environmental hazards.

Reflective questions

How are infection risks for new and existing equipment, devices and products determined?

How is this information used to inform policies, procedures and protocols for preventing and controlling healthcare-associated infections?

What action has been taken to maintain cleaning standards and services?

Key tasks

  • Develop or review the organisation’s processes for introducing new technologies, devices, products or equipment.

  • Develop or review the organisation’s risk management processes to include the need to identify and respond to infection risks that may be associated with repairs, refurbishment or upgrade of infrastructure, including during the planning stage.

  • Set up or review the processes for handling, transporting and storing linen used in the organisation.

Strategies for improvement

Hospitals

Develop processes for new products

Ensure that processes are in place to assess infection risks when introducing new devices, products or equipment into the organisation. This could be included in the role of a products committee, and may be coordinated by the health service organisation or at a group, corporate, or network or district level. Processes for introducing new technologies, devices, products or equipment should also consider:

  • How new products will be trialled
  • How new products will be introduced
  • What training is required
  • Whether items need to be removed or decommissioned
  • Whether the maintenance program considers infection risks that need to be managed (for example, by using specialised personal protective equipment, extra cleaning or disinfection to reduce biofilm or microbial contamination, physical barriers)
  • How product recalls will be coordinated
  • How alerts will be managed and responded to
  • How the introduction of a new product or technology aligns with the organisation’s risk management system.

Consult with relevant services

Ensure that the organisation’s risk management program includes the need to consult with relevant services, such as engineering, environmental cleaning, reprocessing of reusable medical devices, and infection prevention and control services:

  • At the planning stage for any repairs, renovations, refurbishment or redevelopment within the organisation
  • At each stage during any repairs, renovations, refurbishment or redevelopment to minimise or manage risks to patients, the workforce, departments and contractors involved both directly and indirectly.

Infection risks to be considered may include:

  • Access
  • Dust
  • Aerosols
  • Air handling
  • Filters and filtration
  • Water quality, biofilms and supply
  • Sewerage and wastewater
  • Infectious agents
  • Waste materials
  • Disruption of services and utilities
  • Patient and workforce safety
  • Extra cleaning and reprocessing requirements.

Review processes for linen handling

Review the movement, supply and handling of clean and used linen in the health service organisation to minimise infection risks associated with linen for both patients and the workforce. This includes linen used for patient care, environmental linen (for example, privacy screens), and linen used by the workforce (for example, theatre scrubs, uniforms). Consider how to:

  • Minimise excess handling
  • Ensure effective containment and storage
  • Optimise traffic flows to minimise contamination of clean linen
  • Reprocess used linen (methods used, and whether this is done by the health service organisation or an external service).

Ensure that any external services are part of the systems for quality improvement and contracts review addressed in the Clinical Governance Standard.

Day Procedure Services

Develop processes for new products

Ensure that processes are in place to assess infection risks when introducing new devices, products or equipment into the organisation. This could be included in the role of a products committee, and may be coordinated by the health service organisation or at a group, corporate, or network or district level. Processes for introducing new technologies, devices, products or equipment should also consider:

  • How new products will be trialled
  • How new products will be introduced
  • What training is required
  • Whether items need to be removed or decommissioned
  • Whether the maintenance program considers infection risks that need to be managed (for example, by using specialised personal protective equipment, extra cleaning or disinfection to reduce biofilm or microbial contamination, physical barriers)
  • How product recalls will be coordinated
  • How alerts will be managed and responded to
  • How the introduction of a new product or technology aligns with the organisation’s risk management system.

Consult with relevant services

Ensure that the organisation’s risk management program includes the need to consult with relevant services, such as engineering, environmental cleaning, reprocessing of reusable medical devices, and infection prevention and control services:

  • At the planning stage for any repairs, renovations, refurbishment or redevelopment within the organisation
  • At each stage during any repairs, renovations, refurbishment or redevelopment to minimise or manage risks to patients, the workforce, departments and contractors involved both directly and indirectly.

Infection risks to be considered may include:

  • Access
  • Dust
  • Aerosols
  • Air handling
  • Filters and filtration
  • Water quality, biofilms and supply
  • Sewerage and wastewater
  • Infectious agents
  • Waste materials
  • Disruption of services and utilities
  • Patient and workforce safety
  • Extra cleaning and reprocessing requirements.

Review processes for linen handling

If linen is used, review the movement, supply and handling of clean and used linen in the health service organisation to minimise infection risks associated with linen for both patients and the workforce. This includes linen used for patient care, environmental linen (for example, privacy screens and curtains) and linen used by the workforce (for example, theatre scrubs, uniforms). Consider how to:

  • Minimise excess handling
  • Ensure effective containment and storage
  • Optimise traffic flows to minimise contamination of clean linen
  • Reprocess used linen (methods used, and whether this is done by the health service organisation or an external service).

Ensure that any external services are part of the systems for quality improvement and contracts review addressed in the Clinical Governance Standard.

Examples of evidence

Select only examples currently in use:

  • Policy documents about evaluating and responding to the risks associated with linen, equipment, devices, products, buildings, furnishings and fittings in the health service organisation
  • Audit results of the handling, transport and storage of linen
  • Contracts with external linen providers that outline the health service organisation’s requirements for managing clean and used linen to minimise infection risks
  • Schedules for maintenance of buildings, equipment, furnishings and fittings
  • Audit results of compliance with the maintenance schedules for buildings, equipment, furnishings and fittings
  • Records of business decision-making about repairs and upgrades to buildings, equipment, furnishings and fittings.
MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established system for evaluating and responding to infection risks.

Small hospitals that are not part of a local health network should develop or review:

  • The organisation’s processes for assessing infection risks associated with the introduction of new technologies, devices, products or equipment
  • The organisation’s risk management processes to include the need to identify and respond to infection risks that may be associated with any repairs, refurbishment or upgrade of infrastructure, including during the planning stage
  • The processes for handling, transporting and storing linen used in the organisation.

Ensure that the organisation’s risk management program includes the need to consult with relevant services, such as engineering, environmental cleaning, reprocessing of reusable medical devices, and infection prevention and control services:

  • At the planning stage for any repairs, renovations, refurbishment or redevelopment within the organisation
  • At each stage during any repairs, renovations, refurbishment or redevelopment to minimise or manage direct and indirect risks to the patients, the workforce, departments and contractors involved both directly and indirectly.

Review the movement, supply and handling of clean and used linen in the health service organisation to minimise infection risks associated with linen for both patients and the workforce. This includes linen used for patient care, environmental linen (for example, privacy screens and curtains) and linen used by the workforce (for example, theatre scrubs, uniforms). Consider how to:

  • Minimise excess handling
  • Ensure effective containment and storage
  • Optimise traffic flows to minimise contamination of clean linen
  • Reprocess used linen (methods used, and whether this is done by the health service organisation or an external service).

Ensure that any external services are part of the systems for quality improvement and contracts review addressed in the Clinical Governance Standard.

Last updated 3rd July, 2018 at 05:09pm
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References

National Health and Medical Research Council. Australian guidelines for the prevention and control of infection in healthcare. Canberra: NHMRC; 2010 (accessed Sep 2017).