Malaysian Hospital Accreditation Standards 4th Edition January 2013

SERVICE STANDARD 5 Prevention and Control of Infection

PREAMBLE

These standards are applicable to effect facility-wide Prevention and Control of Infection Services. The aim of
these services is to identify and minimise the risks of healthcare associated infection and transmission of
infection among patients, families, healthcare providers, staff of contracted services, students and visitors.

TOPIC 5.1: ORGANISATION AND MANAGEMENT

STANDARD 5.1.1

The Prevention and Control of Infection (PCI) Services are organised and administered to provide optimum
support to the goals and objectives of the Facility, and to meet the needs of the Facility and patients.

CRITERIA FOR COMPLIANCE:

5.1.1.1 There are documented purposes which may be termed Vision and Mission statements, goals,
objectives and values in keeping with the scope of the PCI Services. When compiling the
purposes, consideration shall be given to the following:

a) They are what the services want to achieve.

b) The goals of the services are achieved by the objectives as stated.

c) The goals and objectives are consistent with professional standards, guidelines and
relevant legislation.

d) Statements are monitored, reviewed and revised as required accordingly.

5.1.1.2 There is a Hospital Infection and Antibiotic Control Committee (HIACC) chaired by a medical
practitioner with knowledge of and special interest in infection control and consisting of members
from multidisciplines. The committee has:

 Appointment of a Chairperson
 Terms of Reference
 Committee members
 Tenure of membership
 Frequency of meetings

Notes/Explanations

The Terms of Reference of the committee include to institute, direct, review, and modify, as
appropriate, matters relating to infection control.

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The committee has representation from medical, nursing and clinical support services, and by
invitation administration and any other relevant staff.

5.1.1.3 There is a PCI team which is multidisciplinary that has a working relationship and reports to the
HIACC.

5.1.1.4 There is an organisation chart which:

a) provides a clear representation of the structure and function of the Facility’s HIACC and
the reporting relationships of the PCI team to the HIACC;

b) is accessible to all staff;

c) is revised when there is a major change in any one of the following:

 organisation;
 functions;
 reporting relationships;
 goals and objectives;
 staffing patterns.

5.1.1.5 There are written and dated specific job descriptions for members of the PCI team that include:

a) qualification, experience, training and certification required for the position;

b) lines of authority;

c) accountability, functions, and responsibilities;

d) review when required and when there is a major change in any one of the following:

 nature and scope of work;

 duties and responsibilities;
 general and specific accountabilities;
 qualifications required;
 staffing patterns;
 Statutory Regulations.

5.1.1.6 HIACC meetings are held at least once in every four months to discuss issues and matters
pertaining to the operations of the PCI Services. Minutes are kept and accessible to relevant
staff.

5.1.1.7 The Chairman of HIACC who is Head of PCI Services is involved in the planning, management,
and justification of the budget and resource utilisation of the services.

5.1.1.8 The Head of PCI Services is involved in the assignment of staff.

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5.1.1.9 The Head of the PCI Services shall ensure that the staff of the PCI Services complete incident
reports which are discussed by the services with learning objectives and forwarded to the Person
In Charge (PIC) of the Facility.

5.1.1.10 Incidents reported have had Root Cause Analysis done and action taken to prevent recurrence.

5.1.1.11 Appropriate statistics and records shall be maintained in relation to the provision of PCI Services
and used for managing the services and patient care purposes.

5.1.1.12 Where more than one committee have interests in the issues of the PCI Services, there is
evidence of coordination of the actions undertaken or proposed by the committees. Records are
kept on actions taken to identify and correct the cause of any problem.

5.1.1.13 There are safety measures taken to ensure the protection of hospital staff and environment
against healthcare associated infections:

a) staff education;

b) staff health screening including infectious diseases;

c) staff immunisation;

d) staff health record maintenance;

e) provision for adequate and good quality personal protective equipment (PPE);

f) implementation of safety devices;

g) clinical waste management;

h) protocol for post-exposure management for infectious disease and for assignment of
infected person.

i) records shall be kept on action taken to identify and correct the cause of any problem.

5.1.1.14 Provision is made for the personal comfort and safety of patients and staff which include:

a) clean and hygienic facilities;

b) room temperatures are kept at comfortable levels;

c) disinfection and sterilisation areas, equipment and instruments;

d) proper hand hygiene;

e) aseptic techniques for procedures;

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f) practice of standard and additional precautions.

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TOPIC 5.2: HUMAN RESOURCE DEVELOPMENT AND MANAGEMENT

STANDARD 5.2.1

The PCI Services shall be staffed by adequate numbers of appropriately qualified, trained and certified staff to
achieve the objectives. These designated staff shall maintain competency through Continuing Professional
Development (CPD).

CRITERIA FOR COMPLIANCE:

5.2.1.1 The direction by the Head and staffing of the services are provided by individuals qualified by
education, training, experience and certification to meet the demands of the various positions
and to achieve the objectives of the services.

5.2.1.2 The authority, responsibilities and accountabilities of the Head of PCI Services are clearly
delineated and documented in a letter of appointment.

5.2.1.3 The lead infection control nurse (ICN) in-charge shall be trained and certified.

5.2.1.4 The Infection Control Nurse in charge has delegated authority for the supervision and effective
implementation of infection control policies, and is responsible for surveillance of healthcare
associated infections on a systematic and current basis.

5.2.1.5 Sufficient numbers of personnel and support staff with appropriate qualifications are employed to
enable the services to meet the documented purposes. (national norms is 1 ICN: 110 beds)

5.2.1.6 There is a structured orientation programme implemented where new staff including medical
practitioners are briefed on PCI Services, operational policies and relevant aspects of the Facility
to prepare them for their roles and responsibilities.

5.2.1.7 There is evidence of a staff development plan which provides the knowledge and skills required
for staff to maintain competency in their current positions as the demands of the positions evolve.

5.2.1.8 There are continuing education activities for staff to pursue professional interests and to prepare
for current and future changes in practice. There is evidence that staff education and
development needs have been appraised and identified.

5.2.1.9 There is evidence that all staff have the opportunity to attend on-the-job training, in-service
education, and continuing education programmes appropriate to their work including:

a) additional training in the conduct of procedures unique to the services, such as the
operating rooms, obstetrical units, emergency services, special care units, and isolation
rooms etc;

b) education in the prevention of healthcare associated infections and the roles of the staff in
this control;

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c) safety measures in high risks areas such as the central sterilising supply services,
operating theatres, scope rooms, critical care areas, immunocompromised patient areas,
kitchens, laundry, laboratories, and radiation emission areas etc.

5.2.1.10 The Infection Control Team is involved in orientation and in-service education for all staff
including students, volunteers, staff of contracted services, family members and patients where
appropriate.

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TOPIC 5.3: POLICIES AND PROCEDURES

STANDARD 5.3.1

Documented policies and procedures shall reflect the current knowledge on prevention and practice of
infection control services, and they are consistent with the objectives of the services and relevant regulations
and statutory requirements.

CRITERIA FOR COMPLIANCE:

5.3.1.1 There are written policies and procedures for the PCI Services relevant to the scope of services,
complexity of the Facility and level of risks consistent with national and international
requirements.

Notes/Explanations

The policies and procedures cover all preventive and control procedures for all aseptic
techniques and practices related to sterilisation and disinfection, use of personal protective
equipment (PPE), cross-infection and isolation (patients and visitors), central sterilising services,
housekeeping, laundry, food handling, handling of sharps and waste, pharmacy, surgical and
nursing procedures, pathology, engineering, ventilation, maintenance, and all others.

5.3.1.2 Policies and procedures are developed in collaboration with staff, medical practitioners,
Management and where required with other external service providers and with reference to
relevant sources involved.

5.3.1.3 Policies and procedures are dated, authorised, signed and reviewed at least once every three
years and revised as required.

5.3.1.4 New and revised guidelines, policies and procedures are communicated to all staff.

5.3.1.5 There is evidence of compliance with policies and procedures and evidence based guidelines
(Centers for Disease Control and Prevention/Ministry of Health), which include:

a) preventive and control procedures for all aseptic techniques and practices related to
sterilisation and disinfection;

b) use of personal protective equipment (PPE);

c) cross-infection and isolation (patients and visitors);

d) central sterilising supply services;

e) housekeeping;

f) laundry;

g) food handling;

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h) handling of sharps and waste;

i) pharmacy;

j) surgical and nursing procedures;

k) pathology;

l) engineering;

m) ventilation;

n) maintenance, and all others.

5.3.1.6 Copies of guidelines, policies and procedures, relevant Acts, Regulations, By-Laws and statutory
requirements are accessible to staff.

5.3.1.7 Current reference manuals, pamphlets, journals, and books as well as information and scientific
data concerning infection control shall be available for reference and guidance.

5.3.1.8 Regular environmental inspections are conducted throughout the Facility for the purpose of
reviewing policies and procedures related to infection control. Documented evidence allows
evaluation of infection potential, infection control, and identification of ongoing education needs.

5.3.1.9 The HIACC shall be consulted in order to ensure that:

a) proposed demolition, building constructions and renovations are designed in line with
accepted infection control requirements;

b) proposed new equipment intended for patient care conforms to accepted infection control
standards.

5.3.1.10 The HIACC reviews reports on current healthcare associated infections rates, surveillance
studies of infections and infection potentials, and the implementation of infection control policies.
Pertinent findings shall be submitted to the appropriate source for necessary action.

5.3.1.11 Policies and procedures for infectious patients and those requiring isolation and treatment are
available and complied including the following:

a) proper isolation facilities and techniques for all clinical services, which include isolation of
patients with compromised immune systems, airborne infection and newborns;

b) facilities for hand hygiene;

c) the isolated patients receive the same quality of care as is provided throughout the
Facility.

5.3.1.12 The HIACC evaluates and revises the policies and procedures on prevention and control of
infection on a regular basis.
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TOPIC 5.4: FACILITIES AND EQUIPMENT

STANDARD 5.4.1

Adequate facilities and equipment are available to prevent and control the risks of infection throughout the
Facility including disinfection and sterilisation.

CRITERIA FOR COMPLIANCE:

5.4.1.1 There is adequate and proper utilisation of space and equipment for patient management and
staff to enable them to carry out their professional and administrative functions.

5.4.1.2 The use of all medical devices shall comply with the manufacturers’ instructions on prevention
and control of infection.

5.4.1.3 There shall be no recycling of any disposable medical-surgical instruments, equipment or

supplies.

5.4.1.4 Adequate facilities and equipment are available, e.g. appropriate personal protective equipment
(PPE), isolation rooms etc.

5.4.1.5 Isolation facilities for airborne infection and immunocompromised patients must comply with
regulatory requirements.

5.4.1.6 Adequate and appropriate hand washing facilities and alcohol based hand rub shall be available
in all patient, staff and visitor areas.

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TOPIC 5.5: SAFETY AND QUALITY IMPROVEMENT ACTIVITIES

STANDARD 5.5.1

The Head of PCI Services shall ensure the provision of quality performance with staff involvement in the
continuous safety and quality improvement activities of the Services. This can be achieved through actively
monitoring and tracking risks and trends in healthcare associated infections.

CRITERIA FOR COMPLIANCE:

5.5.1.1 There is evidence that the Head of the Service has in a written document assigned
responsibilities to appropriate individuals/committees for safety and quality improvement
activities within the services.

5.5.1.2 There are planned and systematic safety and quality improvement activities that monitor and
evaluate the performance of the services including a plan for action and follow up to ensure that
the action taken is effective in continually improving the quality of care. Innovation is advocated.

5.5.1.3 There are safety and quality improvement activities in place which support the Facility’s safety
and quality improvement activities including tracking and trending of specific performance
indicators not limited to but at least two (2) of the following:

a) percentage of staff trained in Prevention and Control of Infection practices

b) percentage of healthcare associated infections

c) number of resistant organisms to antibiotics within a specified period of time

d) surgical site infection rate (Clean Elective Cases)

Notes/Explanations

Reports are available on indicators include tracking and trending for specific performance
indicators carried out.

5.5.1.4 The Facility takes appropriate action on all emerging and re-emerging diseases and reports to
the relevant authorities.

5.5.1.5 Feedback on results of safety and quality improvement activities are regularly communicated to
the staff.

5.5.1.6 Appropriate documentation of safety and quality improvement activities, including needle stick
injury, specific surveillance studies, and healthcare associated infections are maintained.
Confidentiality of staff and patients is preserved.

5.5.1.7 There are safety and quality improvement activities that address staff safety.

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