Preventing and Controlling Infections Standard

Systems are in place to support and promote prevention and control of infections, improve antimicrobial stewardship, and support appropriate, safe and sustainable use of infection prevention and control resources in the health service organisation.

• How are the health service organisation’s safety and quality systems used to:
• Support implementation of policies and procedures to prevent and control infections
• Identify and manage risks associated with infections
• Support implementation of policies and procedures to improve antimicrobial stewardship
• Identify and manage antimicrobial stewardship risks?

• An infection prevention and control policy that includes risk assessment and risk management strategies based on the hierarchy of controls
• Other relevant policy documents that cross-reference the infection prevention and control policy, for example, the reprocessing policy, the environmental cleaning policy, the outbreak management policy, the building and refurbishment policy, transportation of sharps policy
• Risk register
• Risk assessments and risk management and mitigation plans, action plans or examples of projects undertaken to address risks
• Outbreak management plans
• Incident management system reports and evidence information was used to improve processes
• Surveillance and reporting systems to monitor infection and antimicrobial stewardship risks
• Training documents for infection prevention and control systems
• Minutes of management, policy and quality assurance meetings
• Audit results of compliance with infection prevention and control 

Systems are in place to support and promote prevention and control of infections, improve antimicrobial stewardship, and support appropriate, safe and sustainable use of infection prevention and control resources in the health service organisation.

• How does the organisation:
  • Apply the hierarchy of controls to manage risks associated with infections?
  • Know its antimicrobial stewardship processes are effective?
  • Use key personnel, such as infectious diseases physicians, microbiologists, pharmacists and, CSSD, environmental cleaning, and infection prevention and control staff, to identify and manage infection risks?
  • Prepare the organisation and its workforce for public health and pandemic risks?
  • Identify training requirements to prevent and control infections, and improve antimicrobial stewardship?
  • Ensure that the workforce has the capacity and skills to implement systems to prevent and control infections and implement antimicrobial stewardship?
  • Ensure that the workforce has access to equipment to implement systems to prevent and control infections and implement antimicrobial stewardship?
  • What processes have been set up to minimise waste generation and costs, whilst also meeting infection prevention and control requirements?

• Policies, procedures and protocols for the procurement, use and monitoring of equipment used for the prevention and control of infections
• Outbreak and pandemic management plans
• Terms of reference and multidisciplinary membership of committee(s)/teams responsible for infection prevention and control
• Terms of reference and multidisciplinary membership of committee(s)/teams responsible for antimicrobial stewardship
• Minute(s) for committees responsible for infection prevention and control and antimicrobial stewardship
• Evidence of assessment of workforce requirements for education and training in relation to infection prevention and control and antimicrobial stewardship
• Certificate(s) of completion for relevant courses and records of competency assessment in relation to infection prevention and control systems and antimicrobial stewardship
• Training logs, schedules or training calendars
• Training curriculums and catalogues that are in use
• Orientation program curriculums
• Evidence of processes to monitor workforce competency and skills relevant to infection prevention and control and antimicrobial stewardship
• Audit results of compliance with infection prevention and control policies and procedures
• Feedback from the workforce and consumers on processes for infection prevention and control antimicrobial stewardship
• Reports to the workforce on actions and outcomes related to infection prevention and control antimicrobial stewardship

Systems are in place to support and promote prevention and control of infections, improve antimicrobial stewardship, and support appropriate, safe and sustainable use of infection prevention and control resources in the health service organisation.

• How are the systems for prevention and control of infections, and the effectiveness of the antimicrobial stewardship program continuously evaluated and improved, and who is involved in the process?
• What systems are used to reduce the risk of infections?
• How are the outcomes of improvement activities communicated to the governing body, management, the workforce, consumers and other organisations?
• What actions or areas for improvement in antimicrobial use were identified in the health service?
• How is antimicrobial use assessed for appropriateness?
• What processes are in place to monitor the safe and sustainable use of infection prevention and control resources?
• How are issues identified and responded to?
• How is the workforce supported to ensure infection prevention and control resources are used safely and sustainably?

• Policies on the safe and sustainable use of infection prevention and control resources
• Evidence of monitoring the effectiveness of infection prevention and control processes and outcomes
• Evidence of monitoring the effectiveness of antimicrobial stewardship processes and outcomes
• Evidence of the use of quality improvement systems to implement, evaluate and improve infection prevention and control strategies
• Ongoing quality improvement plan that is informed by:
  • review of data from existing infection control and antimicrobial stewardship monitoring systems (for example, infection surveillance programs such as the National Alert System for Critical Antimicrobial Resistances (CARAlert), Australian Passive AMR Surveillance, hospital-acquired complications and readmissions data, antimicrobial prescribing and usage data, implementation of the National Hand Hygiene Initiative, incident management systems, PROMS data, the National Notifiable Diseases Surveillance System)
  • quality improvement activities related to infection prevention and control performance and antimicrobial stewardship
  • audit results of workforce compliance with policies and procedures for infection prevention and control, and antimicrobial stewardship (where applicable), hand hygiene audits
  • feedback from consumers and the workforce about processes and systems related to infection prevention and control, and antimicrobial stewardship
• Reports to the governing body, the workforce, patients and other relevant groups on the performance of infection prevention and control systems and antimicrobial stewardship outcomes
• Reports of the organisation's performance on infection prevention and control, and antimicrobial stewardship activities published in the annual report and any other publications, for example, newsletters
• Communication with the workforce and consumers on the effectiveness and outcomes of the infection prevention and control system
• Communication with other healthcare organisations that provide care to the same patient/consumer population on the effectiveness and outcomes of the infection prevention and control systems and antimicrobial stewardship processes used at transitions of care
• Evidence of procurement processes that assess for the safe and sustainable use of infection prevention and control resources
• Evidence of processes in place to monitor the sustainable use of infection prevention and control resources
• Examples of improvement activities that have been implemented and evaluated
• Established workforce training programs
• Use of the organisation’s incident management and investigation system to identify and improve safety and quality activities

Systems are in place to support and promote prevention and control of infections, improve antimicrobial stewardship, and support appropriate, safe and sustainable use of infection prevention and control resources in the health service organisation.

• How are the organisation’s processes for partnering with consumers used to involve consumers and their carers in planning and decision-making about their care in relation to infection prevention and control?
• How does the organisation communicate the quality use of antimicrobials to consumers?
• What consumer resources are available and what process were used to determine their appropriateness for the population(s) served by the organisation?
• How does the organisation evaluate its consumer information related to infection prevention and control and antimicrobial stewardship?
• How does the organisation collect and evaluate feedback from consumers about information provided on infection prevention and control and antimicrobial stewardship?
• When and how often does the organisation provide information to consumers, their carers and the community about infection prevention and control and antimicrobial stewardship?

• Evidence of organisational policies about partnering with consumers on infection prevention and control
• Evidence of consumer engagement in the organisation's infection prevention and control and antimicrobial stewardship programs, such as membership on organisational committees
• Evidence of consumer engagement in the development of consumer resources related to infection prevention and control and antimicrobial stewardship
• Evidence of the availability of consumer-focussed infection prevention and control and antimicrobial stewardship resources to support patients in their decision-making about their care
• Evidence that the organisation provides infection prevention and control and antimicrobial stewardship information to consumers in different modalities
• Observation of the workforce using processes for partnering with consumers
• Where appropriate, the contemporaneous display of posters relevant to consumer populations
• Feedback from the workforce and consumers that demonstrates that the workforce understands the processes for partnering with consumers
• Evidence of how feedback from consumers about the effectiveness of strategies and processes implemented to prevent and control infections is evaluated and used by the organisation
• Evidence of how feedback from consumers about the effectiveness of antimicrobial stewardship strategies and processes is used by the organisation

Systems are in place to support and promote prevention and control of infections, improve antimicrobial stewardship, and support appropriate, safe and sustainable use of infection prevention and control resources in the health service organisation.

• What process and outcomes measures are collected for the surveillance of infection, infection prevention and control processes and antimicrobial stewardship?
• How is information from local, jurisdictional and national surveillance programs used to monitor, assess and reduce risks relating to infections?
• How are outcomes from surveillance reported to the workforce, the governing body, consumers and other relevant groups? How is feedback from these groups used?
• How can the organisation contribute to existing surveillance that is coordinated by their governing, or networked, healthcare organisation(s)?
• What surveillance methods are in place to monitor antimicrobial use and how are they used? In what forum are they discussed and reviewed?
• How does the organisation compare to other similar services with respect to antimicrobial use?

• Evidence of strategies used for the surveillance of infection prevention and control processes and outcomes that are appropriate for the local epidemiology, complexity of the care and treatment provided by organisation
• Evidence of strategies used for the surveillance of antimicrobial stewardship processes and outcomes that are appropriate for the local epidemiology, complexity of the care and treatment provided by organisation
• Evidence of audit processes for monitoring infection prevention and control processes (for example, hand hygiene, environmental cleaning and aseptic technique audits)
• Reports of surveillance activities for infections that are provided to the workforce, governing body, consumers and other relevant groups
• Demonstration of how results of surveillance activities are used to inform the risk management process, and to review or develop policies, procedures and protocols to reduce the risk of infections, for example, quality improvement plans and action plans
• Evidence of participation in mandatory and non-mandatory national surveillance activities relevant to infection prevention and control and antimicrobial stewardship
• Evidence of the organisation reviewing and locally responding to national and/or jurisdictional infection prevention and control and antimicrobial stewardship surveillance outcomes
• Committee and meeting records in which surveillance data on infections are reported and discussed
• Evidence of review of and response to local data from existing national infection prevention and control and antimicrobial stewardship monitoring systems (for example, infection surveillance programs such as the National Alert System for Critical Antimicrobial Resistances (CARAlert), Australian Passive AMR Surveillance, hospital-acquired complications and readmissions data, ion, antimicrobial prescribing and use, implementation of the National Hand Hygiene Initiative incident management systems, PROMS data, the National Notifiable Diseases Surveillance System)
• Examples of evidence-based systems that are used to address risks identified through surveillance activities such as use of transmission-based precautions, environmental cleaning or hand hygiene programs

The risk of infection to patients, the workforce and visitors is minimised by the routine application of infection prevention and control strategies that include standard and transmission-based precautions.

• How does the organisation ensure that its standard and transmission-based precautions are consistent with the Australian Guidelines for the Prevention and Control of Infection in Healthcare?
• How does the organisation apply the Australian Guidelines for the Prevention and Control of Infection in Healthcare in all environments where care is provided?
• How does the organisation ensure that its workforce (including contractors) is implementing standard and transmission-based precautions appropriately and consistent with local policies and the Australian Guidelines for the Prevention and Control of Infection in Healthcare?

• Organisation policy documents about standard and transmission-based precautions that are consistent with the current edition of the Australian Guidelines for the Prevention and Control of Infection in Healthcare
• Training documents (for example, syllabus, attendance records, competency assessments) relating to standard and transmission-based precautions
• Audit results of workforce compliance with standard and transmission-based precautions, hand hygiene and use of personal protective equipment
• Examples of improvement activities that have been implemented and evaluated to raise awareness and improve compliance with standard and transmission-based precautions
• Committee and meeting records in which compliance with, and incidents relating to, standard and transmission-based precautions were discussed
• Observation of infection control signage and other information resources consistent with the Australian Guidelines for the Prevention and Control of Infection in Healthcare
• Competency training documents for aseptic technique and assessing compliance with aseptic technique policies and procedures
• Use of the organisation’s incident management and investigation system to identify and improve safety and quality activities

Infection risks are assessed, managed and monitored, using the hierarchy of controls in conjunction with infection prevention and control systems, and the workforce has the capacity to apply infection prevention and control practices.

• How does the organisation incorporate the hierarchy of controls into its infection prevention and control systems to reduce transmission of infections?
• How is the Communicating for Safety Standard used for developing collaborative and consultative processes to assess and communicate infection risks to consumers, carers and the workforce?
• How does the organisation ensure it keeps updated on emerging evidence, policy and or legislative changes relating to infectious diseases?
• How does the organisation monitor the workforce's:
• Compliance relating to the competent use of standard and transmission-based precautions
• Competent use, testing and fitting of personal protective equipment by the workforce
• How does the organisation ensure that the workforce (including contractors) is trained in the appropriate use of personal protective equipment?
• What processes does the organisation use to improve compliance with standard and transmission-based precautions?

• Policies, procedures and/or protocols that document the organisation’s processes for ensuring the workforce is:
  • using the infection prevention and control systems in conjunction with the hierarchy of controls
  • provided with training in the use, testing and fitting of personal protective equipment
  • supported to work collaboratively and in consultation when assessing and communicating infections risks
  • able to monitor and respond to changes in knowledge, policy and legislation relating to infections
  • compliant and competent in the use of standard and transmission-based precautions
  • able to demonstrate how to put on and remove personal protective equipment
• Observation of collaborative and consultative processes when assessing and communicating infections risks during interactions between clinicians, patients and their families/carers
• Observation of clear and accurate clinical documentation of patients' infection risks
• Observation of implementation of electronic alert flags for infection risks
• Observation of implementation of infection control signage
• Curriculum, schedule, and attendee logs for workforce PPE training
• Attendee logs and documented outcomes for workforce respirator fit testing
• Assessment of workforce competency related to the implementation of standard and transmission-based precautions
• Audit results of workforce compliance with standard and transmission-based precautions (e.g. audits for compliance with hand hygiene, appropriate PPE use, safe sharp handling and use, aseptic technique)
• Evidence of how audit results of workforce compliance with standard and transmission-based precautions are used to improve practice and patient safety
• Evidence of how the outcomes of workforce competency assessment for standard and transmission-based precautions are used to improve practice and patient safety
• Examples of how the organisation monitors changes in scientific and technical knowledge about infections, relevant national or jurisdictional guidance, policy and legislation are monitored and addressed by the organisation
• Feedback from consumers and the workforce on processes for standard and transmission-based precautions

Exposure of patients or the workforce to infectious agents that cannot be contained by standard precautions alone is minimised. Risk is assessed at all access opportunities to the health service organisation, and necessary precautions are implemented and maintained for as long as necessary.

• What resources are developed to support the workforce in correctly applying standard and transmission-based precautions?
• Are resources such as the local Public Health Unit case management protocols used to inform practice relating to management of patients with communicable diseases?
• How does the health service organisation assess the level of environmental cleaning that is required? What processes are in place for assessing the risks associated with ventilation, heating and cooling systems?
• Has the health service organisation considered how it will manage infections risks if any of its buildings are used as emergency accommodation centres, for example, during a natural disaster, or if the facilities are repurposed for use by acute clinical services, for example, during the COVID-19 pandemic?
• How does the workforce determine when to apply standard and transmission-based precautions?
• How does the workforce collaborate on assessing, managing and communicating infection risks when a patient presents for care or is scheduled to receive treatment?
• How are the Comprehensive Care Standard and the National Safety and Quality Digital Mental Health Standards used to assess and support the wellbeing of clients in isolation?

• Evidence of processes used by the workforce to ensure that standard and appropriate transmission-based precautions are used to mitigate the risk of communicable diseases or infectious agents of local, national and international significance (e.g., ordering of procedure lists)
• Committee and meeting records in which infection risks and precautions to manage them were discussed
• Evidence of resources available to support staff to apply appropriate standard precautions and transmission-based precautions whenever required Audit and reports on workforce compliance with policies and processes for standard and transmission-based precautions
• Examples of activities that have been implemented and evaluated to improve assessment and management of infection risks
• Cleaning schedules that outline requirements associated with infection risk
• Observation of workforce appropriately using standard and transmission-based precautions
• Observation of clear and accurate clinical documentation of patients' infection risks at referral, on admission, on presentation for care and for the duration of patient care
• Observation of implementation of electronic alert flags for infection risks
• Observation of implementation of infection control signage
• Observation of appropriate patient placement which includes consideration of infection risks and the risks to the wellbeing of the patient
• Feedback from consumers on workforce compliance with policies and processes for standard and transmission-based precautions
• Observation of physical and environmental controls for managing the risk of transmission of infectious agents
• Observation that relevant equipment, including PPE, is available to the workforce and is used by the workforce
• Examples of policies, processes or care plans that consider the wellbeing of patients in isolation and improvement activities to support patients and carers

Local epidemiology of infections is considered, and a patient’s known or suspected colonisation or infection risks are communicated to an admitting, transferring or referring facility to minimise exposure of patients, the workforce and visitors to infectious agents.

• What data does the organisation review to be informed of infections in the community? How is this data used to manage patient flow and workforce capacity?
• What systems are in place to ensure the appropriate handling of sensitive information related to infection status?
• How are consumers and their carers advised if they have an infection or are colonised with a pathogen? What modalities are used to deliver this information? When is this information delivered? How is it confirmed that the patient and carer understand this information?
• How is the patient's healthcare record used to communicate infection status?
• How does the organisation communicate the consumer's infectious status when care is transferred within or outside the organisation?
• How does the organisation ensure the client’s infectious status is known when admitting a patient or transferring a patient out of its care?
• Does the workforce know how to access consumer factsheets on infectious diseases published by their organisation, jurisdiction or by national organisations?
• How are consumers and their carers informed of the precautions they can take to prevent and minimise the spread of infection? When and how is this information conveyed to consumers and their carers?
• What processes and resources are in place to support consumers and their carers in preventing and minimising the spread of infection?

• Policy documents for the review and response to data on infections in the community
• Policy documents about communicating infections risks when care is transferred within and outside the health service organisations (e.g. handover protocols, discharge summary protocols
• Policy documents about clinical communications and communicating infections risks within the care team and with the patient and their carers
• Audit results of documentation of infectious status
• Audit results of compliance with the processes for communicating infectious status
• Observation of patient healthcare records documenting that the patient has been advised of their infectious status and understands what this information means
• Observation of patient healthcare records documenting that the patient's infectious status was included in the clinical handover (e.g. handover sheets, discharge forms, discharge summary, transfer forms)
• Observation of handover discussion within clinical team that is inclusive of communication of a patient's infectious status (e.g. end of nursing shift handover, transfer of care discussion)
• Observation of post screening or discharge discussion with patient/carer that is inclusive of communication of a patient's infectious status
• Observation of infection status alerts in the electronic healthcare record
• Resources developed and evaluated by consumers about infection risks, and infection prevention and control strategies
• Examples of resources developed and evaluated by consumers, providing information to consumers their families and carers about their infectious status
• Examples of clinical communications where infection status is discussed

Support implementation of a hand hygiene program that is consistent with the current National Hand Hygiene Initiative.

• What processes are used to ensure that the organisation's hand hygiene program is consistent with the current National Hand Hygiene Initiative and with state or territory requirements?
• How is compliance with the current National Hand Hygiene Initiative measured? What action has been taken to improve compliance?
• How and when does the organisation communicate hand hygiene compliance to the workforce, the governing body, consumers and other stakeholders?
• How does the organisation use hand hygiene compliance results to improve hand hygiene by its workforce and infection prevention and control practice?

• Hand hygiene program policy documents that are consistent with the current National Hand Hygiene Initiative and state or territory requirements
• Formative evaluation of the organisation's hand hygiene program, including use and availability of equipment, supplies and products for hand hygiene
• Training documents (for example, syllabus, attendance records or competency assessments) relating to the hand hygiene program
• Processes for auditing hand hygiene compliance within the organisation, including maintaining a registry of current valid auditors
• Evidence of workforce attendance and evaluation of hand hygiene training
• Observation and audit results of workforce compliance with the hand hygiene program
• Evidence of how audit and other data are used to inform strategies to reduce non-compliance or inconsistency with the current National Hand Hygiene Initiative and jurisdictional requirements
• Committee and meeting records in which hand hygiene data and strategies to improvement hand hygiene compliance were discussed
• Evidence of communication with consumers and the workforce about compliance rates and/or other data relevant to the organisation's hand hygiene program
• Memorandums, newsletters, posters or other communication material on hand hygiene provided to the workforce and consumers
• Availability of hand hygiene products or dedicated hand washing basins and promotional material in public areas
• Observation of hand hygiene consumer resources being provided to patients and/or carers as part of patient care discussions
• Feedback from consumers and the workforce on the hand hygiene program

A risk-based process is implemented that will prevent or minimise the risk of introducing infectious agents during clinical procedures and activities.

• What procedures are performed that require aseptic technique?
• How does the organisation monitor compliance with the organisation's aseptic technique policies?
• Who performs procedures that require aseptic technique?
• How and when does the organisation provide the workforce with training in aseptic technique?
• Where is the evidence of workforce training and competency in aseptic technique?
• What processes are used to ensure ongoing competency in aseptic technique?
• How does the organisation ensure that clinicians routinely follow aseptic technique when required?

• Policies, procedures and protocols for the identification and review of clinical procedures and activities for the application of aseptic technique
• Healthcare-associated infections (HAI) surveillance data for rates of infections associated with invasive clinical procedures
• Results of surveys of the workforce where they have been consulted on clinical procedures that require aseptic technique
• Evidence of content and workforce completion of aseptic technique training, including competency-based assessment programs
• Gap analysis of training records to identify members of the workforce where who need further aseptic technique training is required
• Action plan to address gaps in the workforce with regards to aseptic technique training and competency
• Evidence of refresher training provided to workforce to address any gaps in previous training
• Workforce feedback and evaluation of aseptic technique training and assessment programs
• Observational audits to identify compliance with aseptic technique procedures
• Reports on audits of compliance with organisational policies and procedures, including patient healthcare records, consent forms, procedure checklists, stock inventories
• Evidence of compliance with aseptic technique using observational audit tools or procedural check lists
• Review of adverse patient outcomes data such as clinical incident summaries, morbidity and mortality reports or Root Cause Analysis (RCA) data relating to breaches or non-compliance in aseptic technique
• Hand hygiene compliance data
• Meeting minutes and reports where aseptic technique data have been presented
• Feedback from consumers and the workforce on aseptic technique processes
• Consider technological advances to support improving aseptic technique in practice, such as:
  • equipment bundles
  • sterile ‘starter’ packs
  • dedicated trolleys (for example, intravenous, dressing and urinary catheter trolleys).

Infections are minimised by the appropriate selection, safe insertion and maintenance, and timely removal of invasive medical devices. 

• Are organisational policies, procedures and processes for the use of invasive medical devices consistent with the Australian Guidelines for the Prevention and Control of Infection in Healthcare and other relevant national and jurisdictional guidance (i.e., Peripheral Venous Access Clinical Care Standard)?
• How does the organisation monitor the use of invasive devices to reduce client harm?
• What systems are in place for the workforce to use best practice when assessing clinical need and for the selection, insertion, maintenance, review and removal of invasive medical devices?

• Policy documents stipulating the criteria for selection, insertion, maintenance and removal of invasive medical devices, consistent with the Australian Guidelines for the Prevention and Control of Infection in Healthcare and the Peripheral Venous Access Clinical Care Standard
• List of approved invasive medical devices (for example, a register of medical devices) and indication for use
• Policies and processes for procurement, storage, transport, disposal, reuse, fault management and recall of invasive medical devices
• An established process for the safe introduction of new evidence based invasive medical devices
• Committee and meeting records where invasive medical devices are discussed
• Evidence of established training programs and workforce training records
• Feedback from the workforce on training requirements
• Audit results of workforce compliance with processes for the selection, insertion, maintenance and removal of invasive medical devices
• Gap analysis of organisational policies related to invasive devices use, compared with relevant jurisdictional or national guidance
• Review of invasive medical devices infection surveillance data
• Actions taken to manage identified risks with the selection, insertion, maintenance and removal of invasive medical devices
• Review of adverse patient outcomes data such as clinical incident summaries, morbidity and mortality reports or Root Cause Analysis (RCA) data relating to invasive medical devices
• Examples of improvement activities that have been implemented and evaluated.

Health service organisations identify and respond to environmental and infection risks by providing a clean environment for patients and the workforce.

• Does the organisation have an environmental cleaning policy that includes the need to audit compliance?
• What processes are used to maintain a clean and hygienic environment in line with the current edition of the Australian Guidelines for the Prevention and Control of Infection in Healthcare and with state or territory requirements?
• How does the organisation ensure the workforce is trained on cleaning processes for routine and outbreak situations, and novel infections?

Does the organisation use the audit results to improve environmental cleaning processes?

• Policies, procedures and/or protocols for environmental cleaning consistent with the Australian Guidelines for the Prevention and Control of Infections in Health Care and relevant state and territory requirements
• Public health response, pandemic and/or outbreak management plan that incorporates environmental cleaning
• Relevant documentation from committees and other meetings where environmental cleaning policies and procedures are reviewed and discussed
• Contracts with external cleaning providers that outline the health service organisation's policies and procedures
• List(s) of Therapeutic Goods Administration approved cleaning and disinfection products permitted for use in the health service organisation
• Material safety data sheets or chemical register of approved cleaning resources
• Manufacturer's instructions for use of cleaning resources
• Organisational cleaning checklists, schedules and cleaning methodologies
• Environmental risk assessment that includes actions to address identified risks
• Audit results of cleaning programs and their effectiveness
• Improvement or action plans informed by environmental cleaning audits results
• Training programs for the workforce including contractors on environmental cleaning
• Use of the organisation’s incident management and investigation system and risk management system to identify and improve environmental cleaning
• Processes to review and evaluate the effectiveness of the cleaning program such as regular observation and audits of cleaning practices
• Feedback from consumers and the workforce on environmental cleaning
• Results from consumer surveys or complaints and action taken to address gaps.

The health service organisation minimises infection risks to patients and the workforce from equipment, device, product and environmental hazards.

•  Is there an overarching policy or guidelines for the procurement and introduction of new procedures and technology, which require new equipment, devices or products?
• What systems are used to ensure infection control risks are assessed for new capital or minor works, furniture and furnishings?
• How are infection risks for new and existing equipment, devices and products determined?
• Does the organisation have a preventative maintenance program in place?
• Does the organisation have policy and plans in place to respond to novel infections, local outbreaks, epidemics and pandemics?
• How does to the organisation evaluate and respond to infection risks associated with novel infections?
• How does to the organisation evaluate and respond to infection risks associated with public health response or pandemic activities?
• What action has been taken to ensure equipment/devices are cleaned and maintained in accordance with manufacturer’s instructions?
• How does the organisation determine if linen supplies and laundering comply with Standard AS/NZS 4146: 2000 Laundry Practice?
• If a contractor supplies reusable linen, how is this segregated (clean from dirty) and transported?

• Public health response, pandemic and/or outbreak management plan
• Policy documents for evaluating and responding to the risks associated with linen, equipment, devices, products, buildings, furnishings and fittings in both clinical and non-clinical areas
• Policy and procedures for reporting unsatisfactory practices by contracted staff or outsourced services (e.g. cleaning, reprocessing, laundry and linen management, equipment maintenance servicing) in both clinical and non-clinical areas
• Relevant documentation from committees and other meetings where practices such as linen, cleaning, equipment, devices, products, buildings, furnishings and fittings are reviewed and discussed
• Organisation's preventative maintenance plan in both clinical and non-clinical areas  
• Commissioning reports for new or refurbished buildings
• Records of business decision-making about repairs and upgrades to buildings, equipment, furnishings and fittings.
• Maintenance schedules for buildings, equipment, furnishings and fittings in both clinical and non-clinical areas
• Risk assessment and risk management plans for construction or refurbishment
• Audit results of environmental cleaning and handling, transporting and storage of linen
• Contracts with contractors that outline responsibilities for minimising infection risks in both clinical and non-clinical areas
• Evaluation processes for the procurement and introduction of new devices or pieces of equipment (i.e. evaluation form, minutes of meetings, infection prevention and control considerations)

Audit results of compliance with the maintenance schedules for buildings, equipment, furnishings and fittings in both clinical and non-clinical areas

The health service organisation has a risk-based vaccine-preventable diseases screening and immunisation policy and program to protect the workforce, consumers and patients.

• Does the organisation have a workforce immunisation policy in place? Is it consistent with state or territory and national requirements? How does the organisation assess compliance with the policy?
• Does the organisation have a workforce screening policy in place? How does the organisation assess compliance with the policy?
• Is the organisation's workforce immunisation program consistent with the national immunisation guidelines and state or territory requirements?
• How does the organisation’s workforce vaccine preventable diseases screening and immunisation policy and program identify and address risks to the workforce, consumers and patients?
• Does the workforce policy consider actions when members of the workforce do not or cannot follow immunisation guidelines?

•  Policies, procedures and/or protocols for workforce immunisation that are consistent with national guidelines and state and territory requirements
• Committee and meeting records in which the workforce immunisation and screening policies and program as discussed
• Records of workforce immunisation status (i.e. immunisation registry)
• Protocols for placement of members of the workforce based on the vaccination status
• Audit results of workforce compliance with workforce immunisation and screening policies
• Documents accessible to authorised personnel that:
  • identify the requirements for immunisation as part of the recruitment of workforce or placement of contractors and students
  • demonstrate maintenance of workforce immunisation records
  • identify additional immunisation requirements for relevant members of the workforce
  • record immunisation refusals and organisational risk management response to refusals
• Information relating to vaccine-preventable diseases is available to the workforce and consumers
• Risk assessment for workforce, consumers and patients with regards to vaccine-preventable diseases.

The health service organisation has processes for preventing and managing infections in the workforce to minimise the risks to the workforce, patients and consumers, including for novel infections and during outbreaks.

• Are the organisation's policies and processes for preventing and managing infections in the workforce consistent with relevant state or territory work health and safety regulations and the current edition of the Australian Guidelines for the Prevention and Control of Infection in Healthcare?
• Are policies and processes consistent with state and territory public health requirements for workforce screening and exclusion periods?
• Does the organisation's outbreak management plan address monitoring, investigation and management of the workforce?
• How does the organisation encourage staff to not attend work if they are unwell?
• What systems are in place to facilitate workforce compliance with policies and procedures to prevent and manage infections in the workforce?
• What support is provided to members of the workforce who are required to isolate or quarantine following an exposure to, or who have acquired an infection? What systems are in place to ensure their confidentiality?
• How does the organisation ensure high-quality care continues when the workforce numbers decrease as a result of mandatory workforce absences or furloughing?
• How does the organisation monitor and manage the movement of staff between clinical areas, care settings, amenity areas and health service organisations?

• Policies, procedures and/or protocols for preventing and managing infections in the workforce that are consistent with relevant state or territory work health and safety regulation, state and territory public health requirements for workforce screening and exclusion periods, and the current edition of the Australian Guidelines for the Prevention and Control of Infection in Healthcare
• Outbreak management protocols that address workforce monitoring, investigation and management
• Risk assessment and risk management plans that identify risks to the workforce, patients and consumers, including for novel infections
• Protocols for liaison and collaboration with local infectious diseases and public health teams to respond to and manage staff with notifiable infections.
• A register of exposure-prone procedures that take place in the organisation
• Registers of workforce and volunteer orientation and training
• Registers of staff training and competency assessments for exposure-prone procedures
• Availability of a workforce support program
• Maintenance and audit of volunteer schedules including orientation and training records  
• Audits of patient healthcare records where a notifiable disease has been diagnosed, to ensure appropriate follow up of the workforce including volunteers
• Evidence of processes that support the workforce to not attend work when unwell
• Evidence of processes to monitor and manage the movement of staff within the organisation
• Workforce records that detail furloughing and quarantine periods
• Reports from incident and risk management systems and recommendations for improvements
• Evidence of business continuity and communication planning that involves the workforce and consumers that addresses infection prevention and control

Where reusable equipment and devices are used, the health service organisation minimises infection risks to patients and the workforce by ensuring adequate identification of, and procedures for reprocessing, reusable medical equipment.

•  Is there a process for identifying reusable equipment, instruments and devices that need to be reprocessed?
• What processes does the organisation have in place to plan and manage reprocessing requirements for novel and emerging infections?
• How does the organisation ensure that reprocessing of reusable medical devices follows relevant national standards and manufacturers’ instructions?
• How does the organisation identify the patient, the procedure and the reusable equipment, instruments and devices that were used?
• What mechanism does the organisation have in place to identify and communicate to patients at risk of acquiring an infection as a result of the reusable instruments and devices used?
• How is the sterile stock and reprocessed equipment transported, stored and maintained?

• Policies, procedures and/or protocols for processing reusable medical equipment, instruments and devices that are consistent with relevant national or international standards and manufacturer’s instructions for use
• Policies, procedures and/or protocols for the use of reusable medical equipment, instruments and devices
• Risk assessment and management plans for novel and emerging infections that addresses reprocessing requirements
• Risk assessments where there are deviations in the requirements of relevant standards and the manufacturer’s instructions
• A register of approved reusable medical devices
• Access to or copies of manufacturer’s instructions for reusable medical devices
• Records of sterilisation that verify instrument reprocessing is consistent with relevant national or international standards
• Maintenance schedules for equipment used to reprocess equipment, reusable instruments and devices are monitored and reviewed
• Training documents and registers of staff training and competency assessments
• Audit of validation and compliance monitoring systems for sterilisers
• Audits of sterile stock integrity and supply
• Audit and report on workforce compliance with policies for processing reusable medical equipment, instruments and devices
• Relevant documentation from committees and other meetings where reports on reprocessing processes and traceability systems are reviewed and discussed
• Register or record of consumers who have had procedures using reusable instruments and devices
• Observation of a traceability system that allows individual identification of clients and the reusable devices, equipment or instruments used during the care of each client
• Audit of patient healthcare records or surgical lists to identify documentation of   the use of reusable medical instruments and devices
• Report of clinical incidents related to reusable medical equipment, instruments and devices
• Improvement/action plans informed by local audits of current practice, changes in state or territory requirements or national guidance or standards.

The health service organisation has systems for the safe and appropriate prescribing and use of antimicrobials as part of an antimicrobial stewardship program.

• Is there an overarching AMS program (including policies and procedures), which supports the needs of the health service organisation?
• What systems, processes and structures does the health service organisation have in place to support appropriate prescribing and use of antimicrobials?
• Is antimicrobial prescribing consistent with the Therapeutic Guidelines: Antibiotic eTG?
• Is there an infectious disease physician, clinical microbiologist or pharmacist resource available to the health service organisation if required?
• In what ways is access provided to current endorsed Therapeutic Guidelines: Antibiotic eTG for clinicians who prescribe antibiotics?
• How do staff access prescribing guidelines?
• How is compliance with the policy assessed?
• How is compliance data used to inform quality improvement activities?

• An AMS policy incorporating:
  • governance systems, processes and reporting processes
  • prescribing processes in accordance with therapeutic guidelines
  • list of restricted antimicrobials and approval processes
  • specialist or senior clinical review and referral processes
  • education processes
  • regular policy review processes
  • review and evaluation processes to assess the effectiveness of the AMS program
• A documented organisational chart that describes AMS responsibilities in the health service organisation
• Results of risk assessments to identify areas of priority for an effective AMS program
• Restriction, approval or review systems to guide the use of antimicrobials, where relevant
• Orientation manuals, education resources and records of attendance at training by prescribers and the clinicians administering antimicrobials on antimicrobial usage, development of resistance, and judicious prescribing
• Documented AMS improvement or action plan
• Observation that resources and guides, such as the Therapeutic Guidelines: Antibiotic eTG are available to prescribers and the workforce
• Relevant documentation from multidisciplinary committees with relevant expertise and other meetings where the AMS program is reviewed, discussed and decisions on actions to improve the AMS program are agreed upon
• Referral process to infectious disease physician or clinical microbiologist for use of restricted agents, and that systems are in place to inform prescribers of these procedures
• Access to the Therapeutic Guidelines: Antibiotic eTG is provided for all clinicians authorised to prescribe
• Locally adapted guidelines that are consistent with current endorsed Therapeutic Guidelines: Antibiotic eTG
• Results of risk assessments to identify areas of priority for an effective AMS program
• An antimicrobial formulary that aligns with recommendations in current evidence-based Therapeutic Guidelines: Antibiotic eTG or local guidelines
• Evidence of incorporating the principles of the Antimicrobial Stewardship Clinical Care Standard into the AMS program

Use of audits, process or outcome measures to monitor implementation of the AMS program, and to identify opportunities for improvement

The health service organisation has systems for the safe and appropriate prescribing and use of antimicrobials as part of an antimicrobial stewardship program.

• What processes are in place to collect and evaluate data on antimicrobial use?
• How does the health service use surveillance data on local antimicrobial resistance and use this to support appropriate prescribing?
• What actions have been taken to improve the effectiveness of the AMS processes, for example, ensuring endorsed antibiotic treatment protocols are followed?
• How are data on prescribing and use of antimicrobials reported to clinicians and the governing body?

• Committee and meeting records in which compliance with the AMS policy, and antimicrobial prescribing and use were discussed, including reviews of surveillance data. This should include records of actions arising from meetings and progress on these actions
• Results of analysis of surveillance data on antimicrobial resistance and action taken to improve AMS
• Results of audits and surveys about appropriateness of prescribing, example include results from the National Antimicrobial Prescribing Survey (NAPS) and actions taken to improve the AMS program. Participation in NAPS is not mandatory, health service organisations can choose any tool that best suits their needs and context.
• Examples of improvement activities for AMS that have been implemented and evaluated
• Implement or review the process for reporting adverse events, incidents and near misses relating to antimicrobial use, including assessment and management of reported antibiotic–allergy mismatch
• Communications with clinicians on antimicrobial use, resistance and stewardship
• Memorandums, newsletters or other communication material provided to the workforce and consumers on appropriate use of antimicrobials, including feedback received from consumers
• Record of prescribers completing antibiotic prescribing modules, such as those provided by NPS MedicineWise
• Regular reports to the governing body on the effectiveness of the AMS program
• Contributions to organisational annual reports on the performance of the AMS program