By

Prof. OSSAMA RASSLAN

Secretary General, Egyptian Society of Infection Control

Overview

Accreditation standards for hospitals 1

I. Patient centered standards:

Access to care & continuity of care (ACC) Patient & family rights (PFR) Assessment of patients (AOP) Care of patients (COP)

Patient & family education (PFE)

Overview

Accreditation standards for hospitals 2

II. H.C. Organization mgt standards:
Quality mgt & improvement (QMI) Prevention & control of infections (PCI)

Governance, leadership & direction (GLD)

Facility mgt & safety (FMS) Staff qualifications & education (SQE) Management of information (MOI)
Overview

Prevention & Control of Infections (Overview)

The Goal is:
To identify & reduce the risks of acquiring & transmitting infections among: Patients, staff, doctors & others.

Infections are either: Acquired in the hosp. or Infections brought into the hosp. Nosocomial infections may be: endemic (common cause) or epidemic (special cause)
Overview

Prevention & Control of Infections (Overview)

Prevention & control of infection covers a broad range of processes & activities, both in direct patient care & in patient care support, that are coordinated and carried out by

the hospital.
Overview

Prevention & Control of Infections (Overview)

The IC program may differ from org. to org. according to: Geographic location Patient volume Patient population served Type of clinical activities Number of employees
Overview

Prevention & Control of Infections (Overview)

Effective IC programs have in common:

Identified leaders

Appropriate policies & procedures

Staff education Coordination throughout the org.

Overview

Prevention & Control of Infections (Overview)

Infection control is a quality mgt function.
The IC Officer (ICO)and the QM professional work closely together.

The specific role of the QMP in the IC program

is to assist in standards interpretation & to ensure that data & interventions generated by the IC program are fully integrated into the performance improvement process.

The QMP serves as a consultant to the ICO.

Overview

A.Focus of the IC program (Standards)

The organization designs, implements & uses a coordinated process to reduce the risks of nosocomial infection in patients & H.C. workers.

Processes are implemented for:

1. Cleaning , disinfection& sterilizing equipment

2. Use of disinfectants & disinfecting procedures 3. Availability & use of gloves, masks, soap & disinfectants 4. Waste disposal 5. Disposal of sharps & needles 6. Handling & disposal of blood & blood components Overview

A.Focus of the IC program (Standards)

Processes are implemented for:
7. Separating Pts. with communicable Ds.(Isolation) 8. Designating sites with significant inf. risk 9. Patients with indwelling catheters 10. Managing hemorrhagic patients 11. Laundry & linen management 12. Kitchen sanitation, food preparation & handling 13. Operation of the mortuary & the P.M. area 14. All patient, staff & visitor areas are included in the IC program Overview

B.Management of the program (Standards)

15. One or more qualified individ. oversee all IC activities (education, training, experience or certification) 16. A designated individ. or group monitors & coordinates IC activities in the organization 17. Coordination involves medicine, nursing & others 18. IC program is based on current scientific knowledge, accepted practice guidelines, app.law & regulation 19. Information mgt systems support the IC program

Overview

A & B Intent statement

IC program should be comprehensive

(Patient care & employee health)

IC program processes & activities are based on

current scientific knowledge, accepted guidelines , applicable law & regulation

Processes are documented & address important

epidemiological issues
Overview

A&B Intent statement

Important epidemiological issues:

- Device-related infections - Surgical site infections - Nosocomial infections in ICU - Infections by AB resistant organisms - Nosocomial T.B. - Infections in neonates

Overview

C.Program Integration with QM (Standards)

The IC program is integrated with the overall process for assessing & improving performance
1. The org. tracks infection risks, rates & trends 2. Monitoring includes using indicators for infections issues that are epidemiologically important 3. Org. uses risk, rate & trend information to design & modify processes to reduce nosocomial inf. 4.Org. compares IC rates with other organizations 5. Results of inf. monitoring are communicated to staff, doctors & management 6. Org. reports inf. to appropriate public health agencies Overview

C.Program Integration with QM

Intent statement
The org. must monitor nosocomial inf. risks, rates & trends The org. uses the information to improve the PCI activities & reduce nosocomial inf. as much as possible Rates & trends in similar organizations may help in making use of monitoring data (benchmarking) A committee from all professional groups in the org.

is responsible for the monitoring activities

Overview

D.Education of staff about program (Standards)

The org. provides education on IC practices to staff, doctors, patients, & others. 1. All staff receives an orientation to organizations IC policies & practices 2. All staff is periodically educated in IC when new policies are implemented or significant trends are noted in surveillance data.

Overview

D.Education of staff (Intent Statement)

To have an effective IC Prog, Org. must educate staff about Prog. when they begin work and regularly thereafter. Education Prog. includes professional staff, clinical and non-clinical support staff, and others if appropriate. Education focuses on policies, procedures and practices that guide the Org.s IC program. Education also includes the findings and trends from the monitoring activities.

Overview