Infection Control Program
INFECTION CONTROL PROGRAM
TABLE OF CONTENTS
Infection Control Program Overview ............................................................... 4
Infection Control Plan ....................................................................................... 7
Job Description – Infection Preventionist ......................................................... 8
Infection Control Committee ..........................................................................10
Authority of the Infection Control Committee ...............................................11
Infection Control Committee Minutes Form ..................................................12
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Infection Control Program
Infection Control Program Overview
I.
GOALS
II.
The goals of the Infection Control Program are to:
A.
Decrease the risk of infection to patients and personnel.
B.
Monitor for occurrence of infection and implement appropriate control measures.
C.
Identify and correct problems relating to infection control practices.
D.
Maintain compliance with state and federal regulations relating to infection
control.
SCOPE OF THE INFECTION CONTROL PROGRAM
The Infection Control Program is comprehensive in that it addresses detection, prevention
and control of infections among patients and personnel.
THE MAJOR ACTIVITIES OF THE PROGRAM ARE:
A.
SURVEILLANCE OF INFECTIONS WITH IMPLEMENTATION OF
CONTROL MEASURES AND PREVENTION OF INFECTIONS
There is on-going monitoring for infections among patients and personnel and
subsequent documentation of infections that occur.
Prevention of spread of infections is accomplished by use of Standard Precautions
and other barriers, appropriate treatment and follow-up, and employee work
restrictions for illness.
Staff and patient education focuses on risk of infection and practices to decrease
risk. Policies, procedures and aseptic practices are followed by personnel in
performing procedures and in disinfection of equipment. Immunizations are
offered as appropriate to patients and personnel to decrease the incidence of
preventable infectious diseases.
B.
OUTBREAK INVESTIGATION
Systems are in place to facilitate recognition of increases in infections as well as
clusters and outbreaks.
C.
POLICY AND PROCEDURE REVIEW AND REVISION
Policies and procedures for infection control are reviewed on a regular schedule
and updated as needed.
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Infection Control Program
III.
D.
STAFF EDUCATION
Training of staff in infection prevention begins with orientation of new hires and
occurs at least annually.
E.
QUALITY ASSURANCE (Q.A.)
Infection prevention is a component of the facility’s quality assurance program
and infection prevention reports are made to the QA committee. In addition,
infection prevention rounds are made to assess the level of quality provided and
actions for improvement are taken as needed.
F.
CONSULTATION
The infection preventionist serves as a resource for all staff and all departments
relating to prevention of infections.
DIVISION OF RESPONSIBILITIES FOR INFECTION PREVENTION
ACTIVITIES
The Medical Director is ultimately responsible for the Infection Control Program.
A.
INFECTION PREVENTIONIST
Responsibility is delegated to the Infection Preventionist (IP) to carry out the
daily functions of the Infection Prevention Program. Those functions are
described in the IP job description. The IP has knowledge and interest in
Infection Prevention.
B.
INFECTION CONTROL COMMITTEE
The Infection Control Committee meets on a regular basis and provides input and
direction for the Infection Control Program. Policies and procedures relating to
Infection Prevention are approved by the committee. Reports of infections are
presented to the committee which recommends actions and control measures
when needed.
NOTE: If a formal Infection Control Committee is not used, the facility may have
an oversight group which includes leaders of the organization, to provide
direction to the infection prevention function.
IV.
REPORTING MECHANISMS FOR INFECTION PREVENTION
A.
Patient infection cases are monitored by the IP. The IP completes the line listing
of infections and the monthly report forms and:
1.
Reports to the Infection Control Committee
2.
Reports to the Surgical Nurse Manager and others as directed
3.
Provides feedback to staff as needed.
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Infection Control Program
V.
B.
Employee infections are reported by the employee to the employee's supervisor,
then to the IP or Occupational Health Nurse. The IP/OHN completes the
employee infection report form and reports:
1.
To the Infection Control Committee
2.
To the Infection Prevention/Occupational Health Supervisor and others as
directed.
C.
Compliance with infection prevention practices is monitored and documented by:
1.
Staff evaluation
2.
Observation of Practices
The IP, Infection Prevention Department Supervisor, and appropriate
Department Managers review the compliance monitoring and initiate
appropriate actions.
UPDATING THE INFECTION CONTROL PLAN
The Infection Control Plan will be reviewed annually by the Infection Control
Committee.
NOTE:
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Policies and procedures of the Infection Control Plan may be found in the
Infection Control Manual. Minutes of the Infection Control Committee
meetings are maintained.
Infection Control Program
Infection Control Plan
PURPOSE
To develop and maintain a written plan for infection prevention including an assessment of risk,
services provided, the population served, strategies to decrease risk, and a surveillance plan.
POLICY
I.
A current written infection prevention plan will be implemented.
II.
The written plan will include:
A.
B.
C.
D.
E.
F.
Assessment of risk
Assessment of services provided
Assessment of the population served
Prioritized strategies to decrease risk
Evaluation of effectiveness of strategies
Surveillance plan based on analysis of previous data.
III.
The written infection control plan will guide the activities of the infection prevention
department.
IV.
The plan will be updated at least annually and more often as needed (e.g., changes in
services provided, risks, etc.).
V.
The written plan with the evaluation of effectiveness of the strategies may facilitate
development of an annual summary of the infection prevention program.
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Infection Control Program
Job Description
POSITION TITLE:
Infection Preventionist
REPORTS TO:
Nurse Manager
JOB SUMMARY:
Evaluates quality of patient care and patient outcomes as they relate to
healthcare-associated infections; collects, prepares and analyzes
healthcare-associated infection data; presents infection data and makes
recommendations for actions; monitors employee compliance in use of
barriers and infection prevention measures; prepares and presents
educational offerings for the staff; serves as a resource to all departments
and personnel.
QUALIFICATIONS:
1.
2.
3.
4.
5.
Holds a current state license as an LPN, RN or medical technologist or has equivalent
health care experience.
Completion of a basic training program for infection prevention.
Certification in Infection Prevention is desired.
Ability to develop policies and procedures.
Ability to teach and evaluate clinical performance.
DUTIES AND RESPONSIBILITIES:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Does on-going monitoring of healthcare-associated infections.
Identifies infection prevention problems and makes recommendations for corrective
action.
Prepares the agenda for the Infection Prevention Committee.
Monitors infection prevention practices and employee compliance.
Serves as a resource for all departments and personnel.
Initiates, reviews, and revises infection prevention policies and procedures.
Conducts outbreak investigation and initiates control measures.
Reports communicable diseases to the state as required by law.
Provides educational offerings for orientation and on-going inservices.
Consults with department heads and physicians as needed to improve care.
Initiates follow-up on employee/patient exposures to communicable diseases.
Participates in quality improvement activities.
Participates in short and long range planning for the infection prevention department.
Performs other duties as directed.
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PHYSICAL AND SENSORY REQUIREMENTS
(With or without the aid of mechanical devices)




Must be able to move intermittently throughout the work day.
Must be able to speak and write the English language in an understandable manner.
Must be able to cope with the mental and emotional stress of the position.
Must possess sight/hearing senses or use prosthetics that will enable these senses to
function adequately so that the requirements of the position can be fully met.
 Must function independently, have flexibility, personal integrity, and the ability to
work effectively with patients, personnel, and support agencies.
 Must meet the general health requirements set by the policies of this facility which
may include a physical assessment.
 Must be able to assist in the evacuation of patients during emergency situations.
Acknowledgment
I have read this job description and fully understand the requirements set forth therein. I hereby
accept the position of Infection Preventionist and agree to perform the identified essential
functions in a safe manner and in accordance with the facility’s established procedures. I
understand that as a result of my employment, I may be exposed to blood, body fluids, infectious
diseases, air contaminants (including tobacco smoke), and hazardous chemicals and that the
facility will provide to me instructions on how to prevent and control such exposures. I further
understand that I may also be exposed to the Hepatitis B Virus and that the facility will make
available to me, free of charge, the hepatitis B immunization.
I understand that my employment is at-will, and thereby understand that my employment may be
terminated at-will either by the facility or myself, and that such termination can be made with or
without notice.
Signature- Infection Preventionist
Date
Signature - Supervisor
Date
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Infection Control Program
Infection Control Committee
I.
RESPONSIBILITY:
The Infection Control Committee is responsible for the investigation, control, and
prevention of healthcare-associated infections. Department Heads are responsible for
monitoring staff performance to insure that the policies and procedures are executed. The
Infection Control Committee meets on a regular basis. The committee may meet as part
of the Quality Assurance Committee.
II.
PURPOSE:
Prevention and control of healthcare-associated infections.
III.
AUTHORITY:
To take immediate and appropriate action to correct any issues relating to infection
prevention that creates a hazardous condition.
IV.
REPORTING:
The IP prepares infection reports and presents them to the committee. Areas for
improvement are identified and actions are planned for resolution.
V.
MEMBERSHIP:
The Infection Prevention Committee is composed of the following: (nurse, MD,
pharmacist, housekeeping, sterilization personnel, scrub tech)
A.
B.
C.
D.
E.
F.
G.
H.
I.
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Infection Control Program
Authority of the Infection control Committee
PURPOSE
To delegate authority to the Infection Control Committee to take actions in emergency/crisis
situations.
POLICY
Authority is given to the Committee through the Infection Preventionist (IP) and/or the Chairman
to make the necessary decisions or take appropriate actions if there is deemed to be a danger to
patients or employees related to infections or infection control.
Administrator/CEO
Date
Chairman, Infection Prevention Committee
Date
Chief, Medical Staff/Medical Director
Date
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Infection Control Program
Infection Control Committee Minutes
Minutes of:
Date
Chairman:
Location:
Attending:
Absent:
Time
Topic:
Discussion Recommendations:
Actions:
Follow-up:
Old Business:
HAI/SSI:
CAI/Patients:
Employee Infections:
Revisions P&P Plan
Review Recommended New Products/Equipment
Education
 Annual
 Orientation
 Individual
Compliance Monitoring
 Hand washing
 Terminal cleaning
 Housekeeping
 Sterilization
 Pharmacy
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EX Contract service not
using EPA products to
clean high touch surfaces
Review contract, educate
contractor,
refer to QAPI
Observe cleaning
procedures in 2 weeks
Infection Control Program