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One or more individuals oversee all infection

prevention and control activities. This 1. One or more individuals oversee the
1 infection control program.
individual(s) is qualified in infection control
practices through education, training,
experience, or certification. 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.

There is a designated coordination mechanism


for all infection prevention and control 1. There is a designated mechanism for
2 activities that involves physicians, nurses, and the coordination of the infection
others based on the size and complexity of prevention and control program.
the hospital.
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.

The infection prevention and control program


is based on current scientific knowledge, 1. The infection prevention and control
accepted practice guidelines, applicable laws program is based on current scientific
3 and regulations, and standards for sanitation knowledge, accepted practice
and cleanliness. 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.

Hospital leadership provides resources to


support the infection prevention and control 1. The infection prevention and control
program. program is staffed according to the
4 hospitals size, complexity of activities,
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. Risk-reduction goals and measurable
objectives are established and
reviewed.
1. All patient care areas of the hospital
5.1 All patient, staff, and visitor areas of the are included in the infection prevention
hospital are included in the infection and control program.
prevention and control
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.
The hospital uses a risk-based approach in
establishing the focus of the health care 1. The hospital has established the
associated infection prevention and reduction focus of the program through the
6 program. 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.

The hospital tracks infection risks, infection


rates, and trends in health careassociated 1. Health careassociated infection
6.1 risks, rates, and trends are tracked.
infections to reduce the risks of those
infections.
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


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


actions are implemented to reduce risk
and improve processes.
The organization reduces the risk of infections
through proper disposal of waste. 1. Disposal of infectious waste and
7.2 body fluids are managed to minimize
transmission risk.
The organization reduces the risk of infections
through proper disposal of waste.

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.
The hospital implements practices for safe
handling and disposal of sharps and needles. 1. The hospital identifies and
implements practices to reduce the risk
7.3 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.

The hospital reduces the risk of infections


associated with the operations of food 1. The hospital stores food and
services. nutrition products using sanitation,
7.4 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.

The hospital reduces the risk of infection in


the facility associated with mechanical and 1. Engineering controls are
7.5 engineering controls and during demolition, implemented to minimize infection risk
construction, and renovation. 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.

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.

The organization provides barrier precautions


and isolation procedures that protect 1. Patients with known or suspected
patients, visitors and staff from communicable contagious diseases are isolated in
8 diseases and protects immunosuppressed accordance with recommended
patients from acquiring infections to which guidelines. (Also see ACC.6)
they are uniquely prone.

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.

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. managing patients with airborne
8.1 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. 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.
The hopsital provides education on infection
prevention and control practices to staff,
physicians, patients, families, and other 1. The hospital provides education
11 caregivers when indicated by their about infection prevention and control
involvement in care. 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.