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Committee and Meetings (Infection Control)

Committee and Meetings (Infection Control)

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Published by Clark Barias

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Published by: Clark Barias on May 21, 2011
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10/28/2013

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 LOGODEPARTMENTAL POLICY AND PROCEDURESINFECTION CONTROL DEPARTMENTTitleCOMMITTEE AND MEETINGS (Infection Control)Dr. Albar MedicalHospitalReference No.: Replaces Reference No.: Applies to:Page ___ of ___IC CommitteeEffective Date: Review Date:Prepared by: Reviewed by: Reviewed by:
   S   T   A   M   P
 Approved by: Approved by: Approved by:
1.
 
PURPOSEa.
 
To establish a system that is well coordinated and organized in order to supervise theinfection control activities of the Health Care workers and other ancillary services of Dr. Albarmedical Hospital.2.
 
DEFINITIONa.
 
The committee is composed of Heath Care Workers represented by the different departmentsof the hospital as its members to form the Infection Control Committee.3.
 
RESPONSIBILITIESICD STATEMENT OF AUTHORITY  Acting through the Hospital Director, the Infection ControlCommittee has the authority to:a.
 
Implement the policies and procedures within the hospital in matters of Infection Control.b.
 
It has the authority to investigate potential or real episodes of serious hospital acquiredinfections and, where necessary, to close wards and redirect patients.c.
 
It has the authority to formulate the infection control team within the hospital.d.
 
Education and orientation program for professional staff.e.
 
Surveillance of employees health.f.
 
Standards of hospital domestic cleaning and food hygiene.g.
 
Management of visitors in isolation circumstances.h.
 
Establish and supervision of the Infection Control Team.i.
 
Submit activity report and statistical data to the MOH as required. j.
 
Recommend policies for the prevention of Hospital Acquired Infection and ensure that theyare implemented.k.
 
Maintain records on surveillance, outbreaks, needle stick injury incidents. These are compiledby the Infection Control Team and come up for discussion during the meetings.l.
 
Formulate an antibiotic policy based on the needs of the different specialties and prevalentsusceptibility patterns.m.
 
Implement policies for the safety of health care workers.n.
 
Regulate and give recommendations on any construction or renovation work in the hospital.The plan should be approved by the committee.o.
 
Discuss and find solutions to problems related to infection control encountered by differentdoctors in their specialties.4.
 
POLICYa.
 
The Infection Control Committee meeting is chaired by the Hospital Director/Designee.
 
Title Reference No: Applies to:
COMMITTEE AND MEETINGS (Infection Control)
 IC CommitteePage ___ of ___Effective Date: Review Date Replaces Policy:b.
 
The Infection Control Committee conducts its meetings ___________________.c.
 
Members are represented by different departments of the hospital.d.
 
Each member is issued letters of appointment signed by the Authority.5.
 
PROCEDUREa.
 
The venue of the meeting is held at the conference room every _________________________ _____________________.b.
 
The meeting usually is done for one hour (________ to _________), but extends the times asneeded.c.
 
Pocket of the meeting is given to all members of the committee as soon as statistical reportsare ready. Pocket of the meeting will include:i.
 
Agendaii.
 
Minutes of the previous meetingiii.
 
Nosocomial statistics for the quarterly months.iv.
 
Communicable and Reportable Disease Reports and statistics.d.
 
Members who cannot attend the meeting should be represented by his/her designee.e.
 
ICC Membersi.
 
Hospital Director (ICC Chairman)ii.
 
Assistant Hospital Directoriii.
 
Quality Management Directoriv.
 
Medical Directorv.
 
Chief Operating Officervi.
 
Chief Microbiologistvii.
 
Nursing Serviceviii.
 
Pharmacistix.
 
CSSD and Laundryx.
 
Kitchenxi.
 
OR Supervisorxii.
 
ICU and NICU Headxiii.
 
Housekeeping and Maintenancexiv.
 
Infection Control Directorxv.
 
Infection Control Coordinatorxvi.
 
Infection Control Practitionersxvii.
 
Safety Committeexviii.
 
Supplies Departmentxix.
 
Mortuary Departmentf.
 
Absence of the members shall be minuted and monitoredg.
 
The ICC secretary will document the minutes of the meetingh.
 
Approved minutes of the meeting is given to the Hospital Supervisor and the ICC Members6.
 
CROSS REFERENCE7.
 
FORMSa.
 
Committee Formation orderb.
 
Agenda Distribution Listc.
 
Minutes of the meeting (vacant form)d.
 
Monthly Hospital Nosocomial rates (vacant form)

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