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Guidelines for infection control strategic management planning - Introduction

Page content: 1. Introduction | 1.1 The purpose of the Guidelines | 1.2 Government strategy for infection control in Victoria | 1.3 Goals for Infection Control | 1.4 Outcomes for the Victorian Infection Control Strategy

1. Introduction

Infection control is the responsibility of management and all health care workers and is an integral part of the day-to-day quality and safety operations of any hospital. It is the responsibility of all Metropolitan Health Services and hospitals to ensure the development of infection control programs and infrastructure appropriate for the effective prevention, monitoring and control of infection within their facility.

  • The purpose of the Guidelines
  • The Governments 5 point Infection Control Strategy Plan
  • Key priority areas for the 3 year Infection Control Strategic Management Plans
  • An outline of the planning process

These Guidelines make reference to "hospitals" as a general term. The term ‘hospital’ refers to regional, rural and denominational hospitals and as of 1 July 2000, all Metropolitan Health Services.

1.1 The purpose of the Guidelines

These Guidelines are designed to provide assistance and support for the development of infection control strategic management plans to implement the Government’s infection control strategic framework. They outline five key areas to be addressed by hospitals (acute and sub-acute care) in the planning and enhancement of infection control.

The Guidelines provide a step by step approach, including developing strategic directions, setting priorities, and writing up a Strategic Management Plan.

The Guidelines have been structured to take you through the planning process, and also provide some planning tools and suggested resources that you may find helpful.

1.2 Government strategy for infection control in Victoria

Infection control is a priority issue for the government and recent publicity given to infection control has highlighted its importance. The government has committed $33 million funding over the next 4 years to provide a more co-ordinated approach to infection control and employ an additional 30 infection control practitioners. The Department is working on a number of initiatives to implement the Government’s policy. The importance of using the 30 practitioners to best effect, the implementation of a system for surveillance of hospital acquired infections, and improved staff infection control are key components of this strategy.

In April, 2000 a comprehensive plan to improve infection control in hospitals was tabled in Parliament by the Minister for Health. The range of infection control measures include the requirement of all hospital Metropolitan Health Services and hospitals to develop strategic plans for infection control (see appendix 1).

To assist with allocation of the additional 30 infection control practitioners, the Department requires all hospitals to complete the Infection Control Profile proforma and provide the requested information to the Department by 29 June.

In light of these initiatives, to assist with allocation of funding over the next three years, the Department requires all hospitals to report on implementation and expenditure of existing Infection Control Plans, review the effectiveness of existing plans, and identify and outline future objectives and priorities for effective infection control and prevention, and to improve its strategic management to the Department by 16 August, 2000.

1.2.1 Collaborative Planning and Service Delivery

Hospitals are encouraged to develop their infection control services through collaborative planning and the establishment of strategic links between service providers. Funding is being provided to:

  • Develop a strategic infection control management plan that covers the whole Metropolitan Health Service, region or consortium of hospitals ( further information on a consortia approach is described in appendix 7). Plans should include details of budget allocations.
  • Identify a senior member of management who will act as the executive sponsor for infection control, to lead the development of infection control services and to foster management commitment and support to infection control.
  • Work toward the achievement of specific key outcomes within negotiated time frames. Section 1.4 of this document provides details on the five key priority outcome areas.

1.2.2 Funding and timelines

All hospitals will receive $4,500 as seeding funding for the development of their Infection Control Plans. This will occur as one-off funding in June 2000.

It is anticipated that around $33 in total will be allocated to Infection Control and Cleaning over the next 4 financial years. Approximately $3 million annually of the total funding will go towards improving hospital cleaning standards.

Timelines for submission of Infection Control Strategic Management Plans

The Effectiveness Unit of the Quality and Care Continuity Branch would like to receive the Infection Control Profile proforma by 29 June, and the report on implementation and expenditure of existing Infection Control Plans and new Infection Control Strategic Management Plans by 15 August. Please contact Mary Draper (96168209) or Melissa Aberline (96168558), if you have any queries on this. We would be grateful if you could provide this information by the above dates addressed to:

Melissa Aberline
Senior Project Officer
Effectiveness Unit
Quality & Continuity Care Branch, Acute Health Division
16th Floor, 555 Collins Street

1.2.3 Accountability

All hospitals will need to submit annual reports over the next 3 years to the Quality and Care Continuity Branch. The Branch is keen to develop reporting framework which promotes ongoing communication between agencies and the Unit whilst meeting monitoring and accountability requirements.

The reporting framework for the Infection Control Strategic Management Plans are as follows:



  • Infection Control Profile proforma
  • Infection Control Presentations to the Department
  • Report on implementation and expenditure of existing plans
  • Infection Control Strategic Management Plans (ICSMP)
  • State-wide infection control resurvey
  • ICSMP Progress Report
  • 12 Month annual report
  • State-wide infection control meetings with all hospitals
  • 29 June
  • 13-14 July
  • 15 Aug
  • 15 Aug
  • Oct-Dec
  • 30 Jan, 2001
  • 30 May 2001
  • June 2001

1.3 Goals for Infection Control

There are 3 principal goals for hospital infection control and prevention programs regardless of the health care setting or service mix:

  • Protect the patient;
  • Protect the health care worker, visitors, and others in the health care environment, and
  • Accomplish the previous goals in a timely, efficient, and cost-effective manner, whenever possible.

1.4 Outcomes for the Victorian Infection Control Strategy

The overall desired outcome of the Victorian Infection Control Strategy is the implementation of evidence based practice. Critical to this is the implementation of the NH&MRC Guidelines, Australian Standards, the Department Human Services Guidelines and relevant best practice guidelines.

The 1998 Infection Control Taskforce Report outlined a number of specified outcomes to be achieved by all Metropolitan Health Services and non-network hospitals. These included:

  • a review of structure, management and leadership of infection control programs;
  • existence of effective infection control policies and practices;
  • adoption of guidelines and standards, including adherence to Australian Standard AS4187 for the cleaning, disinfection and sterilisation of medical/surgical instruments and equipment;
  • establishment of risk management and OH&S programs;
  • establishment of nosocomial infection surveillance systems;
  • establishment of education and training programs for all health care workers;
  • maintenance of environmental cleanliness and surveillance of the physical environment, and
  • prevention of the emergence and spread of antibiotic resistant organisms.

In light of the Taskforce Report, we have reviewed the required outcomes for the Victorian Infection Control Strategy into five priority outcome areas, in order to assist institutions in developing their plans.

1.4.1 Priority outcome areas

The priority outcome areas identified are:

  • Management commitment, leadership and accountability;
  • Monitoring infection control and reducing infection rates;
  • Prevention of adverse events;
  • Protecting health care workers and visitors, and
  • Surveillance.

These priority outcome areas are explored in more detail in sections 1.4.2-1.4.6. Some possible questions you might consider for each of the priority areas are included in Appendix 7.

All five priority outcomes should be addressed in the Strategic Plans.

1.4.2 Management commitment, leadership and accountability

The Board is responsible for ensuring management supports and allocates appropriate resources for effective prevention, monitoring and control of infection.

Key performance areas

Development of a model for achieving/enhancing multidisciplinary teams
The existence of a multi-disciplinary team in the delivery of infection control services is seen to be a crucial element of the Infection Control Service delivery structure.

Link with infectious diseases (rural)
The establishment of formal links with a infectious diseases physician or metropolitan infectious diseases service should be explored by all rural regions or consortia.

The provision of comprehensive and timely communication is an important aspect of infection control, both for the infection control team to receive relevant information and for infection control to convey information to all relevant staff and departments to ensure that best practices are followed. Policies and processes are in place regarding communication and the provision of information and support.

Communication mechanisms have been established between all members of the infection control team, committee, management and service providers.

Provide clinical sponsorship
A member of senior management should be clearly identified as the executive sponsor for the infection control program.

Integrate infection control into quality and planning frameworks
Formal links and integration of infection control into all quality components are clearly identified.

Documented plans
Infection control plans should be developed by the infection control committee, documented, endorsed by the Board and reviewed annually.

The resources for infection control (personnel and non-personnel) should be proportional to the size, casemix and estimated infectious risks of the populations served to fulfil the functions of the infection control program. The Plan should clearly identify current infection control practitioner resources and projected resource requirements. Infection control should be the responsibility of at least one designated person and the hours dedicated to infection control clearly defined. The person with this designated responsibility should have specific knowledge and training relevant to infection control and access to other educational opportunities that will increase their capacities in the field.

1.4.3 Monitor IC and reduce infection rates

Interruption of the transmission of or potential transmission of infectious disease, outbreak investigations and control, and performance improvement activities.

Key performance areas

Evidence based IC
Infection Control policies and protocols should reflect current relevant research and evidence based practice.

Capacity to monitor and reduce the emergence of antibiotic resistant organisms
Laboratory based reporting systems are in place to provide relevant information on antibiotic resistant organisms to the infection control team and committee in a timely manner. Antibiotic policies reflect relevant Australian and State guidelines and their effectiveness is routinely monitored.

Infection control risk assessment
Infection control input at initial stages of planning and design to ascertain the risks for susceptible patients and prevention of infection through architectural design. (eg number of isolation facilities, handwashing facilities).

Environmental surveillance
Systems are in place for environmental surveillance. Audit results are routinely reported to the infection control committee and those who need to know. A system is in place for reporting variances or unusual findings promptly to be acted upon.

Disinfection and sterilisation of medical equipment
The Australian Standard AS4187 is adhered to in all departments/units undertaking storage and handling of sterile equipment/stock and equipment cleaning, disinfection and sterilisation.

Education and training
It is essential that health care workers receive at least a rudimentary knowledge of the infection control specific to the setting in which they are employed. This knowledge will allow them to be better able to understand and comply with the practices and procedures necessary for the prevention and control of infections. Educational programs should be evaluated periodically for effectiveness.

Implement standards and guidelines
Compliance with basic accreditation standards, NH&MRC and state guidelines, and Australian Standards relevant to infection control.

1.4.4 Prevent adverse events

The Board has a risk management approach and ensures that senior management support an effective risk management program which incorporates strategies for addressing infection control issues.

Key Performance areas

Written policies and procedures are to be established, implemented, maintained, and updated periodically. Polices should be periodically monitored for effectiveness to ensure compliance, that they fulfil organisational requirements and they have the desired effect in prevention and control of infection.

Consumer information
The provision of good consumer information can be provided at a number of points within the institution and on a number of issues. Information that provides consumers with information on specific relevant health issues or risks and information generally for people who use the hospital regarding the strategies that are in place to protect consumers and their family from infection related risks.

1.4.5 Protect staff and visitors

The Board is responsible for the provision of a safe environment for patients, staff and visitors.

Key performance areas

Employee health
All employees are offered screening and immunisation based on the Immunisation Guidelines for Health Care Workers. The infection control program should institute policies and procedures for the evaluation of exposed or infected staff.

Isolation capacity
The capacity (number and mix of isolation rooms) and personal protective equipment provided to isolate patients with airborne, antibiotic resistant or communicable diseases reflects the casemix, disease risk and services provided. Planning for new or refurbished isolation facilities reflect the Guidelines for Isolation Rooms.

1.4.6 Surveillance

There is a defined program for nosocomial infection surveillance which includes the collection, analysis and reporting back of data to those who need to know and take action.

Key performance areas

  • Conduct surveillance and investigations using epidemiologic principles
  • Use basic statistical techniques to describe the data, calculate rates and critically evaluate significance of findings.
  • Develop a surveillance plan based on the casemix and services provided.
  • Select indicators based on the projected use of the data (eg external benchmarking and internal trending)
  • Use standard definitions for the identification and classification of events, indicators, or outcomes.
  • Evaluate and compare surveillance data to either internal or external data sources.
  • Report significant findings to appropriate parties

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Last updated: 7 June, 2010
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