Action 3.11 states
The health service organisation has processes for aseptic technique that:
- Identify the procedures in which aseptic technique applies
- Assess the competence of the workforce in performing aseptic technique
- Provide training to address gaps in competency
- Monitor compliance with the organisation’s policies on aseptic technique
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?
Examples of evidence
- 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).