Action 3.01 states

The workforce uses the safety and quality systems from the Clinical Governance Standard when:

  1. Implementing policies and procedures for infection prevention and control
  2. Identifying and managing risks associated with infections
  3. Implementing policies and procedures for antimicrobial stewardship
  4. Identifying and managing antimicrobial stewardship risks


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.

Reflective questions

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?

Examples of evidence

  • 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 policies and procedures

See also: