INTERNATIONAL ACCREDITATION

28th of August 2012

Onne Myrna

INTRODUCTION
Infections continue to be a significant health care
challenge.
There is an increase in the number of organisms
that are resistant and virulent.
Patients and health workers alike are at risk for
care-related infections
In the health care settings around the world
present new challenges to efforts to provide safe,
quality care
The environment can also play a major role in
the transmission of organisms

STEPS TO BE SUCCESS
Having leaders who are committed to

addressing the issue

Standardizing processes to decrease
variability
Educating caregivers and staff on their
responsibilities
Using forcing systems when appropriate
Monitoring key metrics to determine
progress

InfectionPrevention: Back to Basics

Hand hygiene
We still fail to perform hand hygiene 100%

of the time

PCI.1
One or more individuals oversee all

infection prevention and control activities

Qualified and certified in infection control
practices ( training/education/experience
)
Full time
Job description

PCI.2
Member of IC Committee & Responsibilities

* Need to be review
JCIA - Recommendation :
* Clinical Depart ( Doctors/specialist/OT )
* FMS ( environmental or facilities services )
* Food services
* Housekeeping services
* Laboratory ( epidemiologist/microbiologist )
* Pharmacy
* CSSD
Minute of meeting

PCI.3
Infection Control Program
Policies and Procedures
Reference ( National and international )

* KemKes RI
* CDC
* WHO

PCI.4
The organizations leaders provide adequate

resources to support the infection control program

ICN /ICLN & Job Description
Training & Education program
Material/Topic of T&E
Information management systems support :
Computer with internet access, Books/Journal

PCI.5
Program /evaluation/action plan
Surveillance of health care associated

infection
INFECTIOUS DISEASES OUTBREAK
MANAGEMENT Policy
Policy and procedure review

PCI.5.1
Patients/staffs/visitors participations in the

infection control program

* Leaflet/brochure/poster
* Education

PCI.6
SURVEILLANCE :

Surgical site infection

VAP
Catheter associated urinary tract infection
Intravascular invasive devices
MDRO
Emerging or reemerging infections e.g. TB,
H1N1

GRAPHIC - SSI

PCI.7
Implementation monitoring to reduce the

risk of infection
* daily observation
* audit
Reviewing of policies and procedures

OTHER ISSUES
Quality Assurance in CSSD

- Autoclave validation ( biological indicators )

- Reporting if the validation is fail
- Quality of water
- Maintenance program
Infection Control During construction,
renovation and maintenance ( policy and
procedure )
Management of TB patient /Patient placement

PC7.1
Adequate equipment cleaning and sterilization

* surgical instrument
* endoscope disinfection
* Cleaning of non invasive patient care
equipments
Proper management of Laundry and linen
( management program )
Policy of reuse of single-devices
Monitoring process of cleaning &
disinfection/sterilization

PCI.7.2 - 4
Policy and procedure of disposal of hospital

waste :
* infectious/blood/body fluid
* waste from mortuary
Policy/procedure of sharps disposal
Management of food service and engineering
controls :
* Kitchen sanitation & food preparation
* Chiller/ice machine/dish washer
* positive pressure/thermostats

PCI.7.5
Policy and Procedure during demolition,
construction and
renovation :
Criteria of risk to assess the impact of renovation
or new construction
Air quality requirement
Noise/vibration anticipation

PCI.8 Isolation Procedures

Barrier precautions and isolation procedure :

* PPE
* Room with special ventilation system
Policies and procedures ( staffs/visitors/cleaning )
URGENT : SOCIALIZATION
Signage : airborne/droplet & contact precaution

PCI.9 Techniques & Hand

hygiene
Using of PPE and Disinfectants
All the facilities are in place, clean and

easy to access and to use

Written Policy/Procedure of HH and surface
disinfection
Hand washing/disinfection poster

PCI.10 1 - 6
Integration of the program with Quality Improvement

and
Patient Safety :
* Quality improvement program ( e.g. HH compliance )
* Rate of health care associated infection result/graphic
should be informed regularly to leaders (CEO/doctors/
nurses )
* Report information on infections to appropriate
external
customer ( public health agency )

PCI. 11- Education Program

Provide education on infection control

practices to staff, doctors, patients,

family/visitors and other caregivers
* orientation of all new staff
* refreshed periodically ( specially :
new
policies/ procedures and practices
Education includes the findings from
the daily monitoring or observation
( SQE.7 ) or patients/families/visitors
opinion

CONCLUSION
Back to Basic : improve hand hygiene

compliance
Washing your hands every time you
should as you carry out your daily
responsibilities.
Follow the infection control policies and
procedures

Infection control belongs to all of us.

It is part of our jobs; it is our
responsibility.