Governance and systems for infection prevention, control and surveillance Overview of what is required Suggested approach Examples of evidence The outcome of risk assessments should be A quality improvement plan in line with that includes strategies to improve infection reviewed by the individual or committee prevention and control. responsible for managing the organisation’s Examples of improvement activities that have infection prevention and control system and used been implemented and evaluated to reduce to inform the: the risks of healthcare associated infection. development and review of infection prevention and control policies, procedures and/or Memos, newsletters or other communication material provided to the workforce and protocols consumers on healthcare associated development and implementation of infections. improvement strategies. These improvement strategies may be the same as those implemented for . 3.4 Undertaking quality improvement activities to reduce healthcare associated infections through changes to practice 3.4.1 Quality improvement activities are implemented to reduce and prevent healthcare associated infections 3.4.2 Compliance with changes in practice are monitored 3.4.3 The effectiveness of changes to practice are evaluated The intent of Item 3.4 is that infection prevention Where relevant, undertake or participate in A risk register in line with that includes and control programs incorporate quality and quality improvement activities that are conducted actions to address identified risks. safety principles to reduce infection rates. Actions by the overarching health service organisation. A quality improvement plan in line with that 3.4.1 to 3.4.3 relate to the implementation of an shows implementation, regular review, If your community health service is responsible overarching quality improvement approach to revision and evaluation of outcomes. for implementing quality improvement activities, infection prevention and control. Appendix 1 A log of activities conducted as part of a you should: outlines the steps for using a quality improvement quality improvement model such as engage clinicians and consumers to evaluate approach. data and information on infection rates and Data reports collected and monitored from risks The activities undertaken as part of , , , , , and pre- and post-quality initiatives. may also be used to demonstrate compliance with conduct a review of existing infection control Outcomes and results of checklists and audits these actions. measures to identify areas for improvement of infection control processes provided by brainstorm strategies to address the issues You should monitor any improvement activities external safety and quality organisations. identified undertaken to reduce infection risks to:
Governance and systems for infection prevention, control and surveillance Overview of what is required Suggested approach Examples of evidence The outcome of risk assessments should be reviewed by the individual or committee responsible for managing the organisation’s infection prevention and control system and used to inform the: development and review of infection prevention and control policies, procedures and/or protocols development and implementation of improvement strategies. These improvement strategies may be the same as those implemented for . A quality improvement plan in line with that includes strategies to improve infection prevention and control. Examples of improvement activities that have been implemented and evaluated to reduce the risks of healthcare associated infection. Memos, newsletters or other communication material provided to the workforce and consumers on healthcare associated infections. 3.4 Undertaking quality improvement activities to reduce healthcare associated infections through changes to practice 3.4.1 Quality improvement activities are implemented to reduce and prevent healthcare associated infections 3.4.2 Compliance with changes in practice are monitored 3.4.3 The effectiveness of changes to practice are evaluated The intent of Item 3.4 is that infection prevention and control programs incorporate quality and safety principles to reduce infection rates. Actions 3.4.1 to 3.4.3 relate to the implementation of an overarching quality improvement approach to infection prevention and control. Appendix 1 outlines the steps for using a quality improvement approach. The activities undertaken as part of , , , , , and may also be used to demonstrate compliance with these actions. You should monitor any improvement activities undertaken to reduce infection risks to: Where relevant, undertake or participate in quality improvement activities that are conducted by the overarching health service organisation. If your community health service is responsible for implementing quality improvement activities, you should: engage clinicians and consumers to evaluate data and information on infection rates and risks conduct a review of existing infection control measures to identify areas for improvement brainstorm strategies to address the issues identified A risk register in line with that includes actions to address identified risks. A quality improvement plan in line with that shows implementation, regular review, revision and evaluation of outcomes. A log of activities conducted as part of a quality improvement model such as Data reports collected and monitored from pre- and post-quality initiatives. Outcomes and results of checklists and audits of infection control processes provided by external safety and quality organisations.
Guide-to-the-NSQHS-Standards-for-community-health-services-February-2016.docx