2 Standards & Objective element A standard is a statement that defines the structures and processes that must be substantially in place in an organization to enhance the quality of careObjective element is measurable component of a standardAcceptable compliance with objective elements determines the overall compliance with a standard,
4 Standards-1The organization has a well defined ,comprehensive and coordinated Hospital Infection Prevention & Control (HIC) programme aimed at reducing and eliminating risks to patients,visitors and health care workersa.HIC program is documented which aims at preventing and reducingrisk of hospital associated infections.b.HIC program is a continuous process and updated at least once ayear.c.The hospital has multi-disciplinary infection control committee whichcoordinates all infection prevention and control activities.d. The hospital has infection control team.e. The hospital has infection control officer as part of ICTf . The hospital has a infection control nurse as part of ICT
5 Standards-2The organization implement the policies and procedures laid down in the Infection Control Manuala. The organization identifies the various high risk areas andprocedures and implement policies and procedures to preventinfection in theses areas.AreaICU/NICUOTPost Operative wardBlood BankCSSDLab/EndoscopyProcedures-Cardiac Catheterization-Endoscopy-Surgery-IV infusion-Central line insertion
6 Standards-2b. The organization adheres to standard precautions at all times( Standard precautions include a group of infection preventionpractices that apply to all patients regardless of suspected orconfirmed infection status in any setting in which healthcareis delivered)- Hand Hygiene- Use of gloves- Gown- Mask- Eye protection/Face shield- Safe injection practicesStandard precaution are also intended to protect patients byensuring that HCW do not carry infectious agents to patientson their hands or via equipments used during patient care
7 Standards-2 c. The organization adheres to hand hygiene guideline. d. The organization adhere to safe injection and infusionpractices.e. The Organization adheres to transmission based precautionsat all times.f. The organization adheres to cleaning, disinfection andsterilization practices.g. The organization adhere to laundry and linen management.h. The organization adhere to kitchen sanitation and foodhandling issues.i. An appropriate antibiotic policy is established and implementedj. The organization has appropriate engineering control toprevent infection (Air conditioning of OT/ICU)k. The organization adhere to housekeeping procedures
8 Standards-3Organization performs surveillance activities to capture and monitor infection prevention and control data.a. Surveillance activities are appropriately directed towards thehigh risk area.b. Collection of surveillance data is ongoing process.c. Verification of data is done on regular basis.d. Scope of surveillance activities incorporates tracking andanalyzing of infection rate, risks and trend .e. Surveillance activities including monitoring the compliancewith hand hygiene guideline .f. Surveillance activities include monitoring the effectivenessof housekeeping services.g. Feedback on HAIs are provided on regular basis toappropriate personnel.
9 Standards-3h. In case of notifiable disease information is sent to appropriateauthoritiesHAI indicators-UTI rate-VAP rate-SSI rate-CRBSI rate-Incidence of PhlebitisHCW safety indicator-Incidence of NSINursing care indicator-Incidence of bed soreafter admission
10 Standards-4The organization takes actions to prevent and control HealthcareAssociated Infections in patientsa. The organization takes action to prevent urinary tract infection.b. The organization takes action to prevent respiratory tract infection.c. The organization takes action to prevent intra vascular deviceinfection.d. The organization takes action to prevent SSI.e. The organization takes action to prevent phlebitis.
11 Standards-5The organization provides adequate and appropriate resources forprevention and control of Healthcare Associated Infectionsa. Adequate and appropriate PPE,soaps and disinfection areavailable and used correctly.b. Adequate and appropriate facilities for hand hygiene in allpatient care area accessible to HCW .c. Isolation and barriers nursing facilities are available.d. Appropriate pre and post exposure prophylaxis is provided to allconcerned staff members .
12 Standards-6The organization identifies and takes appropriate action to controloutbreak of infectionsa. Organization has a documented procedure for identifying anoutbreak.b. Organization has a documented procedure for handling outbreak .c. The procedure is implemented during outbreak.d. After the outbreak is over appropriate corrective actions aretaken to prevent recurrence.
13 Standards-7There are documented policies and procedures for sterilization activities in the organization.a. Organization provide adequate space and appropriate zoning forsterilization activities.b. Documented procedure guides the cleaning packing disinfectionsterilization, storing and issue of items .c. Reprocessing of equipment and instruments are covered.d. Regular validation test for sterilization are carried out.e. There is an established recall procedure when outbreakin the sterilization system is identified.
14 Performance/Validation test Bowie Dick test (daily)Leak rate test (weekly)Temperature and process control test (weekly)Air detector performance test (weekly)Biological indicator test (weekly)- Bacillus stearothermophillus: steam- Bacillus subtillis:ETO and Dry heatQuarterly test (using thermocouples)(Usually done by company once in six months)Yearly commissioning and re-commissioning test(using thermocouples)
15 Standards-8Biomedical waste (BMW) is handled in an appropriate and safemanner.a. Organization adhere to statutory provision with regards to waste.b. Proper segregation and collection of BMW from all patient carearea of the hospital is implemented and monitored.c. The organization ensures that Biomedical Waste is stored andtransported to the site of treatment and disposal in proper vehiclewithin stipulated time limits in a secure manner.d. Bio medical waste treatment facility is managed as per statutoryprovision( if in house) or outsourced to authorized contractors .e. Personal protective measure are used by staff handling BMW
16 Standards-9Infection control program is supported by management and includestraining of staffs.a. Management makes available resources required for the infectioncontrol program.b. The organization earmarks adequate funds from its annual budgetin this regards.c. The organization conducts induction training for all staff.d. The organization conducts appropriate in service training sessionfor all staff at least once in 6 month for nursing staff and once ina year for doctors