Action 3.02

Integrating clinical governance

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Action 3.02 states

The health service organisation:

  1. Establishes multidisciplinary teams to identify and manage risks associated with infections using the hierarchy of controls in conjunction with infection prevention and control systems
  2. Identifies requirements for, and provides the workforce with, access to training to prevent and control infections
  3. Has processes to ensure that the workforce has the capacity, skills and access to equipment to implement systems to prevent and control infections
  4. Establishes multidisciplinary teams, or processes, to promote effective antimicrobial stewardship
  5. Identifies requirements for, and provides access to, training to support the workforce to conduct antimicrobial stewardship activities
  6. Has processes to ensure that the workforce has the capacity and skills to implement antimicrobial stewardship
  7. Plans for public health and pandemic risks

Intent

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 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?

Examples of evidence

  • 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

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