1. Infection Prevention and Control Committee in a Health Care Facility (HCF) Christine Mukashema Infection Prevention and Control Manager, KFH

2. Objectives
Understand the importance for an Infection Prevention and Control Committee (IPCC) in a Health Care Facility (HCF)
Describe the reasons for creating an Infection Prevention and Control Committee in a HCF

3. Functions of an Infection prevention and Control Committee in a Health care setting
Develops IPC education programmes for hospital staff
Strives to minimize the risks of health care associated infections (HCAI)
Formulates, implements and revises infection control policies and procedures
4. Discusses any infection prevention and control related problems brought to them
5. Advises on the purchase of equipment where applicable

4. Functions of an Infection prevention and Control Committee in a Health care setting
Reports on the incidence and prevalence of alert organisms, important infectious diseases
7. Reviews outbreaks of infection and advice on how outbreaks must be managed and might be prevented
8. Assists in the planning and development of services and facilities in the hospital that are relevant to infection control

5. Functions of an Infection prevention and Control Committee in a Health care setting
9. Monitors and advises on specific areas for hygiene and infection control e.g. catering, CSSD, ventilation, water services, occupational health, pharmacy, theatre, endoscopies etc 10. Receives the monthly report of infection control statistics from different service units within the facility 11. Ensures that reports are acted upon by management

6. Functions of an Infection prevention and Control Committee in a Health care setting
12. Ensures compliance with standards in respect of infection prevention and control services 13. Promotes co-operation between departments regarding infection prevention and control 14. Advises management on all aspects of infection control in the hospital 15. Documents visits to clinical and non clinical areas and report at regular intervals as prescribed by hospital policy

7. Terms of Reference
A competent and active infection prevention and control committee is a most important part of any programme for prevention and control of health care associated infections (HCAI) among patients and personnel.

8. IPCC Membership:
The Infection Prevention and Control Committee (IPCC), is a multi-disciplinary committee. It includes representation from the Hospital administration, Department of Nursing, Medical Staff, and the Infection Control Department.

9. IPCC Membership:
The committee members are representatives of the following departments:
Senior Management
The department of Nursing
The department of Clinical Medicine
Medical ward
Surgical ward
Paediatric ward
Maternity ward
Theatre/CSSD
OPD
Dental Department
The Occ H&S Service
Laboratory
The Infection Control Nurse
Pharmacy
House keeping
Laundry
Catering

10. IPCC Membership:
The Chairperson shall be elected by the committee on a yearly basis
Representation from Maintenance, Health Records, and other ancillary staff will be used on a consultative basis

11. Meetings: The committee shall meet twice a month
Meetings shall be held with more than one half (50%) of the members present, otherwise the meeting shall continue as an ad hoc meeting
If two successive ad hoc meetings occur, binding decisions may be taken in the second meeting

12. Meetings:
Minutes of the meetings and documentation of the recommendations made shall be kept and submitted to the Senior Management Committee within one week of a meeting.

13. Lines of communication:
The IPCC must be a subcommittee of the Senior Management Committee
The Chairman has the authority to institute appropriate control measures or studies when there is considered to be a danger to patients or personnel

14. Authority:
The IPPC has the authority to demand compliance with IPC policies and guidelines in all departments
Hospital department managers have line responsibility for implementation of these policies

15. Responsibilities:
Recommendation on all aspects of hospital policy relating to infection prevention and control. Administration is responsible for prompt review and implementation of recommended infection control policy formulated by the committee
Review of all data concerning infections and infection risks. Through the Infection Control Nurse, the Infection Control Committee shall be kept informed of infections within and outside the hospital of epidemiological significance.

16. Responsibilities:
Initiation and supervision of the investigations and the reporting of:
3.1 clusters of infections above expected
levels,
3.2 single cases of unusual nosocomial infections, and
3.3 other infection control studies and surveys.
4. Initiation of audits of the Hospital’s IPC practices and submission of the related reports to Senior Management

17. Responsibilities: 5. Feedback of surveillance data to staff
6. Review of the capabilities/practices of specific departments:
Laboratory’s microbiological services
The CSSD
The Kitchen
The Laundry
Theatre

18. Responsibilities:
7. Approval of all chemicals used for disinfection and all methods used for sterilization within the hospital 8. Recommendations for the purchase/ provision of all IPC equipment 9. Recommendations related to the educational needs of hospital staff in relation to IPC

19. Possible IPC Activities
Surveillance
Clinical waste management quality project
Hand hygiene audit
Three data collection exercises
Infection control practices general audit
Notification of wound and other sepsis
Hand washing techniques audit

20. Infection Prevention and Control Audits in a Health Care Facility
Christine Mukashema
Infection Prevention and Control Manager,
King Faisal Hospital

21. Learning Objectives
Indicate the role of an IPC Audit in a health care setting
List some of the use of the IPC Audit data
Discuss the importance of the IPC Audit of a Health care settings

22. Background
Infection prevention and control (IPC) is an important dimension of safe care and an integral aspect of day-to-day care
It is a hospital-wide function and is the responsibility of those providing service
Thus everyone working in a healthcare facility (HCF) has a part to play in ensuring the implementation of Infection Prevention and Control standards

23. Background
Non compliance to infection control standards and guidelines is associated with increase in Health Care Associated Infections (Rockville 2008)
Infection control audits to evaluating clinical practice is one of the most effective strategies in the prevention of HCAIs (Madani, 2006)
The study aimed to determine the impact of infection control audits on infection control standards compliance

24. Principle goals for IPC
To protect the patient
To protect the healthcare worker (HCW), visitors, and others in the healthcare environment
To accomplish the above in a cost effective manner, wherever possible.
The level of IPC service is a good indicator of the standard of excellence of the care provided

25. IPC Audits Purpose
There are several reasons for conducting an IPC Audit
Generally it is hoped that the results will contribute to:
The delivery of safe health care;
Provision of an environment that drives improvement in quality, safety and accountability;
An audit will help to establish the level of IPC service as a baseline for improvement

26. IPC Audits Purpose
Establish the current infection control practices used across the hospital
Promotion of continuous quality improvement through regular monitoring and evaluation of IPC services; and attainment of best practices in IPC
Identify the gap between those current practices and international standards
Provide baseline data for further development of an IPC Service

27. How to Audit: Setting of Standards and indicators
Hospital
Service/Department
Standards
All services and departments must reach 100% compliance levels with IPC best practices
Each service/ department must reach full compliance
Indicators
Proportion of services/departments who have reached 100% compliance
Degree of compliance of each service/department

28. Audit tools establishment
Established an audit tools form
The criteria outlined in the tools vary according to department

29. IPC Audits
Following receipt of the initial results, monthly departmental internal audits should be completed by the department managers or their delegate, and the infection control Link Personnel

30. Departments to be assessed
Infection Prevention &Control
Neonatal Intensive Care Unit
Intensive Care Unit
Out Patients Department
Accident & Emergency
Surgical
Urusaro
Medical
Paediatrics
Central Sterile Supply Department
Physiotherapy
Dental
Pharmacy
Laboratory
Radiology
Maintenance
Kitchen
Laundry
Mortuary
Stores
Maternity
Theatre

31. Important Criteria to be assessed
Administration
Audit
IPC Committee
Education
Risk Management
IPC Guidelines/ Standards
Clinic /dressing room
Kitchens
Housekeeping
Hand washing
Isolations precautions
Linen management
Waste management
Environmental hygiene
Bathrooms/Showers/Toilets
Sluice room
Urinary catheters

32. Criteria to be assessed
Respirator equipment
Scrub up rooms
Ventilation
Autoclave
Protective clothing
Patient’s personal hygiene
Layout
Storage
Biosafety cabinet
Change rooms
Aseptic technique
Specimens
Equipment
Cleaning material
Disinfectants
Refrigerators
Food hygiene
Staff
Water supply
Hydrotherapy pool
Intravascular devices

33. IPC Audit data analysis
The IPC Audit data will help in identifying IPC issues in different areas which will include:
Management
People
Policies
Material
Measurement, and
Method

34. Root Causes: Possible causes of the IPC gaps
Management
People
Policy
Policy on Audit not known
Form not yet known by some staff
Poor understanding of IPC needs?
Staff availability for education sessions
Problem reported not resolved for a long time
Insufficient emphasis on importance of IPC Audit from HOU, HoDs
Staff still require education about IPC
Delayed/slow responses from Hosp. Admin. when a problem is reported from the audit
Staff still require education re policies & practices
IPC Audit gap
Auditing not yet implemented in practice in the hospital
Processes need to be learned
Management of change issues
Repeated stock outs
Policies not yet implemented
Ignorance on how to do audit
Financial issues
Measurement
Method
Material

35. Possible causes of the IPC gaps
Quality Problem identification
Specific Problem Statement

36. IPC Compliance
An assessment of 80% or above reflects compliance to IPC best practices that represents the desired state to which the whole hospital and each department or service must work toward achieving

37. Choose possible solutions
Unless the problem in question is the sole responsibility of an individual, developing solutions should be a team effort.
Although solutions are of different natures, often, they are rooted in management systems related to supervision, training and logistics.

38. Monitor change & improvements
Teams should modify solutions as needed and should fully document the results and lessons learned.
Once the solution has proved to be effective, the new process must be documented and disseminated so that others can learn from the experience.

39. Monitor change & improvements
Develop an action plan using a Project plan Template/tool
Implement solutions - this requires careful planning, therefore the team must determine

40. Ex: Project plan Template/ Tool
PLANNED ACTIVITIES
RESOURCES
REQUIRED
RESPONSIBLE
PERSON
ESTIMATED START DATE
ACTUAL START DATE
ESTIMATED END DATE
ACTUAL END DATE
COMMENTS

41. IPC Audits
IPC Audits should be done every months and comparison should be done for improvements

42. Some IPC audits results
June 2009
Feb 2010
Sept 2010
June 2011
May 2012
Nov 2012
June 2013
65%
76%
81%
74%
73%
82%
88.8%

43. Some IPC audits results
Departments
Baseline
Feb 2010
Sept 2010
June 2011
May 2012
Nov 2012
June 2013
IPC 51 79 99 91 73 87 85
NICU 62
76.6 92 93
98.3
ICU 71 84 96
94.5 81 89
97.7
OPD 57
77.6 83 88
83.4
81.8
Renal
Service not yet established
64.5
87.5
Urusaro
65.9
88.5
89.7
Medical 46
75.5 76 77 69
91.2
Maternity 70
74.3 63 78
86.3

44. Some IPC audits results
HDU
Service not yet established 61 79 77
A&E 70
82.2
64.5 74 76 80
Surgical 40 63 71 52 57
78.9
Theatre
85.5 78 94 97
Pediatrics 64
86.8 85
CSSD
90.9 96 89 82 92
Physiotherapy 68 87 95
94.5
Dental 73 81 75
88.8

45. Some IPC audits results
Pharmacy 57 76 84 72 93 82
85.5
Laboratory 66 90
77.5
70.5 89
Radiology 64 73 86 63
78.6
Maintenance 59 40 53 67 58
Kitchen 77 80 71 74
Laundry
86.3
Mortuary 48
72.7 78
Stores 56
82.9 54
Total 65 81
82.3
88%

46. Some IPC audits results

47. Some IPC Audits results

48. Some IPC Audits results

49. Some IPC Audits results

50. Recommendations
Regular infection control audits in all healthcare facilities
Infection control audits to form part of our hospital’s quality improvement processes
Forums for sharing knowledge and information

51. Conclusion
IPC Audit will help in the monitoring and the evaluation of IPC activities
Will help also in planning and making strategies for improvement if needed
‘To measure is To know’
“If you cannot measure it, you cannot improve it”
Lord Kelvin

52. Thank you!