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