One or more individuals oversee all infection
prevention and control activities. This
1 infection control program.
individual(s) is qualified in infection control
practices through education, training,
experience, or certification.
There is a designated coordination mechanism
for all infection prevention and control
2 activities that involves physicians, nurses, and the coordination of the infection
others based on the size and complexity of
the hospital.
The infection prevention and control program
is based on current scientific knowledge,
accepted practice guidelines, applicable laws
3 and regulations, and standards for sanitation
and cleanliness.
Hospital leadership provides resources to
support the infection prevention and control
program.
4 hospitals size, complexity of activities,
1. One or more individuals oversee the
2. The individual(s) is qualified for the
hospitals size, complexity of activities,
and level of risks, as well as the
programs scope.
3. The individual(s) fulfills program
oversight responsibilities as assigned or
described in a job description.
1. There is a designated mechanism for
prevention and control program.
2. Coordination of infection prevention
and control activities involves
physicians and nurses, and others
based on the size and complexity of the
hospital.
3. Coordination of infection prevention
and control activities involves infection
prevention and control professionals.
1. The infection prevention and control
program is based on current scientific
knowledge, accepted practice
guidelines, and local laws and
regulations.
2. The infection prevention and control
program is based on standards from
national or local agencies for sanitation
and cleanliness.
3. Infection prevention and control
program results are reported to public
health agencies as required.
4. The hospital takes appropriate action
on reports from relevant public health
agencies.
1. The infection prevention and control
program is staffed according to the
and level of risks, as well as the
programs scope.
 Hospital leadership provides resources to
support the infection prevention and control
program.

2. Hospital leadership allocates and

approves staffing and resources
required for the infection prevention
and control program.

3. Information management systems

support the infection prevention and
control program.
The hospital designs and implements a
comprehensive program to reduce the risks of 1. There is a comprehensive program
health careassociated infections in patients that crosses all levels of the hospital, to
5 and health care workers. reduce the risk of health care
associated infections in patients.

2. There is a comprehensive program

that crosses all levels of the hospital to
reduce the risk of healthcare
associated infections in health care
workers. (Also see SQE.8.2)

3. The program incorporates a range of

strategies that includes systematic and
proactive surveillance activities to
determine usual (endemic) rates of
infection.

4. The program includes systems to

investigate outbreaks of infectious
diseases.

5.1 All patient, staff, and visitor areas of the
hospital are included in the infection
prevention and control
The hospital uses a risk-based approach in
establishing the focus of the health care
associated infection prevention and reduction focus of the program through the
6 program.
The hospital tracks infection risks, infection
rates, and trends in health careassociated
6.1
infections to reduce the risks of those
infections.
5. Risk-reduction goals and measurable
objectives are established and
reviewed.
1. All patient care areas of the hospital
are included in the infection prevention
and control program.
2. All staff areas of the hospital are
included in the infection prevention
and control program. (Also see SQE.8.2)
3. All visitor areas of the hospital are
included in the infection prevention
and control program.
1. The hospital has established the
collection of data related to a) through
f) in the intent.
2. The data collected in a) through f)
are analyzed to identify priorities for
reducing rates of infection.
3. Infection control strategies are
implemented to reduce the rates of
infection for the identified priorities.
1. Health careassociated infection
risks, rates, and trends are tracked.
2. Processes are redesigned based on
risk, rate, and trend data and
information.
3. The hospital assesses the infection
control risks at least annually and takes
action to focus or refocus the infection
prevention and control program.
 The hopsital identifies the procedures and
processes associated with the risk of infection 1. The hospital has identified those
7 and implements strategies to reduce infection processes associated with infection
risk. risk. (Also see MMU.5, ME 1)

2. The hospital has implemented

strategies, education, and evidence-
based activities to reduce infection risk
in those processes.

3. The hospital identifies which risks

The organization reduces the risk of infections
by ensuring adequate equipment cleaning and
sterilization and the proper management of
laundry and linen.
7.1
require policies and/or procedures,
staff education, practice changes, and
other activities to support risk
reduction.
1. Methods for medical technology
cleaning, disinfection, and sterilization
address the principles of infection
prevention and control.

2. Methods for medical technology

cleaning, disinfection, and sterilization
are coordinated and uniformly applied
throughout the hospital.

3. The principles of infection prevention

and control are applied to laundry and
linen management, including
transportation, cleaning, and storage.

The hospital identifies and implements a

process for managing expired supplies and the 1. The hospital implements a process
reuse of single-use devices when laws and consistent with national laws and
7.1.1 regulations permit. regulations and professional standards
that identifies the process for managing
expired supplies. (Also see ACC.6)

2. When single-use devices and

materials are reused, the hospital
implements a process that addresses
items a) through f) in the intent.

3. Data are used to identify risks, and

The organization reduces the risk of infections
through proper disposal of waste.
7.2
actions are implemented to reduce risk
and improve processes.
1. Disposal of infectious waste and
body fluids are managed to minimize
transmission risk.
 The organization reduces the risk of infections
through proper disposal of waste.
The hospital implements practices for safe
handling and disposal of sharps and needles.
7.3
The hospital reduces the risk of infections
associated with the operations of food
services.
7.4
The hospital reduces the risk of infection in
the facility associated with mechanical and
7.5 engineering controls and during demolition,
construction, and renovation.
2. The handling and disposal of blood
and blood components are managed to
minimize transmission risk.
3. Operation of the mortuary and
postmortem area are managed to
minimize transmission risk.
1. The hospital identifies and
implements practices to reduce the risk
of injury and infection from the
handling and management of sharps
and needles.
2. Sharps and needles are collected in
dedicated, closable, puncture-proof,
leakproof containers that are
not reused.
3. The hospital disposes of sharps and
needles safely or contracts with sources
that ensure the proper disposal of
sharps containers in dedicated
hazardous waste sites or as determined
by national laws and regulations.
1. The hospital stores food and
nutrition products using sanitation,
temperature, light, moisture,
ventilation, and security in a manner
that reduces the risk of infection.
2. The hospital prepares food and
nutrition products using proper
sanitation and temperature.
3. Kitchen sanitation measures are
implemented to prevent the risk of
cross contamination.
1. Engineering controls are
implemented to minimize infection risk
in the hospital.
 The hospital reduces the risk of infection in
the facility associated with mechanical and
engineering controls and during demolition,
construction, and renovation.
The organization provides barrier precautions
and isolation procedures that protect
patients, visitors and staff from communicable
8 diseases and protects immunosuppressed
patients from acquiring infections to which
they are uniquely prone.
The hospital develops and implements a
process to manage a sudden influx of patients 1. The hospital develops and
with airborne infections and when negative- implements a process to address
pressure rooms are not available.
8.1
2. The hospital has a program
developed that uses risk criteria to
assess the impact of renovation or new
construction and implements the
program when demolition,
construction, or renovation take place.
3. The risks and impact of the
demolition, renovation, or construction
on air quality and infection prevention
and control activities are assessed and
managed.
1. Patients with known or suspected
contagious diseases are isolated in
accordance with recommended
guidelines. (Also see ACC.6)
2. Patients with communicable diseases
are separated from patients and staff
who are at greater risk due to
immunosuppression or other reasons.
3. Negative-pressure rooms are
monitored routinely and available for
infectious patients who require
isolation for airborne infections; when
negative-pressure rooms are not
immediately available, rooms with
HEPA filtration systems with a minimum
of 12 air changes per hour may be
used.
4. Cleaning of infectious rooms during
the patients hospitalization and after
discharge follow infection control
guidelines.
managing patients with airborne
infections for short periods of time
when negative-pressure rooms are not
available.
 process to manage a sudden influx of patients
with airborne infections and when negative-
pressure rooms are not available.

2. The hospital develops and

implements a process for managing an
influx of patients with contagious
diseases.

3. Staff are educated in the

management of infectious patients
when there is a sudden influx or when
negative-pressure rooms are not
available.

Gloves, masks, eye protection, other

protective equipment, soap, and disinfectants 1. The hospital identifies situations in
are available and used correctly when which personal protective equipment is
9 required. required and ensures that it is available
at any site of care at which it could be
needed.

2. Personal protective equipment is

correctly used in those identified
situations.

3. Surface disinfecting procedures are

implemented for areas and situations in
the hospital identified as at risk for
infection transmission.

4. Soap, disinfectants, and towels or

other means of drying are located in
areas where hand-washing and
hand-disinfecting procedures are
required.
 The infection prevention and control process
is integrated with the organizations overall 1. Infection prevention and control
program for quality improvement and patient activities are integrated into the
10 safety.
The hopsital provides education on infection
prevention and control practices to staff,
physicians, patients, families, and other
11 caregivers when indicated by their
involvement in care.
hospitals quality improvement and
patient safety program. (Also see GLD.4
and GLD.11)
2. Monitoring data are collected and
analyzed for the infection prevention
and control activities and include
epidemiologically important infections.
3. Monitoring data are used to evaluate
and support improvements to the
infection prevention and control
program.
4. Monitoring data are documented
and reports of data analysis and
recommendations are provided to
leadership on a quarterly basis.
1. The hospital provides education
about infection prevention and control
to all staff and other professionals.
2. The hospital provides education
about infection prevention and control
to patients and families.
3. All staff are educated on the policies,
procedures, and practices of the
infection prevention and control
program.
4. Periodic staff education is provided in
response to significant trends in
infection data.
5. Findings and trends from the
measurement activities are
communicated throughout the hospital
and included as part of periodic
education.