Action 3.03 states

The health service organisation applies the quality improvement system from the Clinical Governance Standard when:

  1. Monitoring the performance of infection prevention and control systems
  2. Implementing strategies to improve infection prevention and control systems
  3. Reporting to the governance body, the workforce, patients and other relevant groups on the performance of infection prevention and control systems
  4. Monitoring the effectiveness of the antimicrobial stewardship program
  5. Implementing strategies to improve antimicrobial stewardship outcomes
  6. Reporting to the governance body, the workforce, patients and other relevant groups on   antimicrobial stewardship outcomes
  7. Supporting and monitoring the safe and sustainable use of infection prevention and control resources

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 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?

Examples of evidence

  • 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

See also: