Action 3.11 states

The health service organisation has processes for aseptic technique that:

  1. Identify the procedures in which aseptic technique applies
  2. Assess the competence of the workforce in performing aseptic technique
  3. Provide training to address gaps in competency
  4. 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.

Reflective questions

  • 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).

See also: