national infection prevention and control guideline
TRANSCRIPT
Administrative Components
National Infection
Prevention and
Control Guideline
General Directorate of Infection Prevention and Control
First Edition 2016
National Infection Prevention and Control Manual
Chapter 1
Infection Control Program
Guideline No:
NIPCM – I – 01
Subtitle:
ADMINISTRATIVE COMPONENTS OF THE IPC PROGRAM
Issuing Authority: General Directorate of
Infection Prevention and Control (GDIPC)
Applies To:
All MOH Healthcare Facilities
Effective Date:
April 2016
Page 1 of 5 General Directorate of Infection Prevention and Control
1. Definition:
1.1 In addition to the clinical aspects of the IPC program, the administrative components of the
program are also essential to identify and to reduce or eliminate the risks of acquiring and
transmitting infections among patients, HCWs and other staff, volunteers, students and visitors.
2. Key Concepts:
2.1 To outline the administrative components of the IPC program.
2.2 To establish the appropriate organizational structure within each level of the health care
system and to have defined roles and responsibilities for key personnel.
2.3 To establish a system for monitoring and evaluation of the compliance to these components .
3. Key Terms:
IPC – Infection Prevention and Control
HCWs – Health Care Workers
ICPs – Infection Prevention Professionals
ICC – Infection Control Committee
HAI – Healthcare Associated Infections
JCI – Joint Commission International
IPC-RD – IPC Regional directorate
ICMC – Infection Control Monitoring checklist
IC – Infection Control
4. Principles:
Infection Control Programs are active on three levels:
4.1 General Directorate of Infection Prevention and Control (GDIPC) - The regulatory body of
Infection Prevention and Control in the Ministry of Health.
4.1.1 GDIPC responsibilities (include but not limited to):
4.1.1.1 Create and update policies, goals, strategies, and national technical guidelines
using the evidence available for IPC using up to date standards and protocols
4.1.1.2 Represents IPC in relationships with other national programs and key
stakeholders
4.1.1.3 Represents IPC in relationships with international organizations
National Infection Prevention and Control Manual
Chapter 1
Infection Control Program
Guideline No:
NIPCM – I – 01
Subtitle:
ADMINISTRATIVE COMPONENTS OF THE IPC PROGRAM
Issuing Authority: General Directorate of
Infection Prevention and Control (GDIPC)
Applies To:
All MOH Healthcare Facilities
Effective Date:
April 2016
Page 2 of 5 General Directorate of Infection Prevention and Control
4.1.1.4 Responsible for the IPC elements of the preparedness plans and strategize the
responses to public-health emergencies due to communicable diseases (e.g.
pandemics)
4.1.1.5 Supervise and evaluate implementation of national technical guidelines in
health care facilities
4.1.1.6 Receive and manage IPC related issues from health regions
4.1.1.7 Follow up and consult on reported outbreaks from regions and provide technical
support
4.1.1.8 Establish scope and the structure of the training in the following:
4.1.1.8.1 Basic training of IPC for HCWs in all regions
4.1.1.8.2 Specialized training of infection-control professionals (technical teams)
4.1.1.8.3 Establish Educational programs e.g. (MOH-JCI IC Diploma program)
4.1.1.9 Coordinate, collect and document the available data on HAIs at the national level
4.1.1.10 Develop a system for surveillance of HAIs in all levels of health care facilities.
4.1.1.11 Develop and monitor the progress of national IPC program.
4.1.1.12 Participate in Hajj activities for preparation training and monitoring all IPC
related activities.
4.1.1.13 Provide statistical analysis on the available data and benchmarking reports for
region’s performance in IPC programs.
4.1.1.14 Prepare an annual report of the achievements and progress on programs and
projects.
4.1.2 Personnel
4.1.2.1 General Director
4.1.2.2 Assistant General Director
4.1.2.3 Director of Planning and Development Department
4.1.2.4 Director of Follow up and Evaluation Department
4.1.2.5 Executive Manager
4.1.2.6 Multidisciplinary staff: infection control professionals (physicians and nurses)
epidemiologist, microbiologist, public health specialists and consultants, total
quality management specialists, medical research, biostatistics specialists,
administrative, IT and secretarial staff.
4.1.3 Reporting:
National Infection Prevention and Control Manual
Chapter 1
Infection Control Program
Guideline No:
NIPCM – I – 01
Subtitle:
ADMINISTRATIVE COMPONENTS OF THE IPC PROGRAM
Issuing Authority: General Directorate of
Infection Prevention and Control (GDIPC)
Applies To:
All MOH Healthcare Facilities
Effective Date:
April 2016
Page 3 of 5 General Directorate of Infection Prevention and Control
4.1.3.1 Administratively: Report to the Assistant Deputy Minister for Preventive
Health.
4.2. Regional Directorate of Infection Prevention & Control (IPC-RD) - Ensures that all MOH
approved guidelines are being implemented (refer to Core Components)
4.2.1 Responsibilities (include but not limited to):
4.2.1.1 Distribute MOH guidelines of IPC to the hospitals and ensure their understanding
of them.
4.2.1.2 Develop an annual auditing plan to monitor the implementation of the IPC
programs in health care facilities in their region.
4.2.1.3 Perform auditing of the facilities and provide recommendations for identified
gaps using ICMC (refer to Core Components).
4.2.1.4 Follow up implementation towards the closure of these gaps
4.2.1.5 Supervise the progress of the programs and projects and collect their forms from
the healthcare facilities in the region and send them according to GDIPC
regulations and memorandums.
4.2.1.6 Manage epidemic outbreaks of health care facilities in the region, by following
the guidelines established by the GDIPC (refer to Core Components).
4.2.1.7 Coordinate with the inter-related departments in the regional directorate to
ensure implementation of the requirements of infection control in health
facilities in that region. This will be achieved through regular meetings of the
infection control committee at regional level (refer to Core Components).
4.2.1.8 Effectively communicate with IPC departments in health care facilities to
evaluate these departments. This will be achieved:
4.2.1.8.1 Using ICMC by the IPC office (refer to Core Components).
4.2.1.8.2 Receiving quarterly auditing results using HOME tab of the ICMC
automated Excel file (refer to Core Components).
4.2.1.8.3 Send Regional Hospital Scoring Tracker to GDIPC semi-annually. (Refer
to Core Components).
4.2.1.9 Ensure availability of all IPC supplies and equipment required at the regional
level.
National Infection Prevention and Control Manual
Chapter 1
Infection Control Program
Guideline No:
NIPCM – I – 01
Subtitle:
ADMINISTRATIVE COMPONENTS OF THE IPC PROGRAM
Issuing Authority: General Directorate of
Infection Prevention and Control (GDIPC)
Applies To:
All MOH Healthcare Facilities
Effective Date:
April 2016
Page 4 of 5 General Directorate of Infection Prevention and Control
4.2.2 Personnel:
4.2.2.1 Medical epidemiologist
4.2.2.2 Infection control professionals (physicians and nurses)
4.2.2.3 Public health professionals
4.2.2.4 IT
4.2.3 Reporting:
4.2.3.1 Administrative: Report to assistant director of public health in the region.
4.2.3.2 Functional: Report all the required reports (as mentioned above or in the core
components) to the General Directorate of Infection Prevention and Control
(GDIPC) through the Regional General Director.
4.3. Infection Prevention & Control Healthcare Facilities consists of:
4.3.1. Infection Control Committees (ICC) (refer to core components) 4.3.2. Responsibility of Infection Control department (include but not limited to):
4.3.2.1. Ensure that all MOH approved guidelines are being implemented. 4.3.2.2. Plan operational processes, activities and resources of infection control
services and ensures that all activities and responsibilities are carried out effectively.
4.3.2.3. Responsible for the department's functions related to surveillance, analysis, and interpretation and reporting of HAIs.
4.3.2.4. Develop an annual training plan for employee education on infection control and prevention related activities (refer to Core Components).
4.3.2.5. Develop an infection control risk assessment annually to be approved by Infection Control Committee (refer to Core Components).
4.3.2.6. Develop IC action plan based on risk assessment annually to be approved by ICC.
4.3.2.7. Prepare, organize and manages the ICC meeting as ICC coordinator (refer to Core Components).
4.3.2.8. Prepare statistical reports on HAIs, compliance rates (ICMC), and other programs compliance (Needle stick injuries, outbreaks, and Hand Hygiene) for the meeting.
4.3.2.9. Review, edit and maintain transcribed ICC minutes. 4.3.2.10. Work effectively with supply department to ensure that all products and
other necessary infection control resources are constantly available. 4.3.2.11. Adhere to all the protocols and policies issued by GDIPC 4.3.2.12. Responsible for communicating all the IPC related data to the IPC-RD. 4.3.2.13. Other duties as assigned.
National Infection Prevention and Control Manual
Chapter 1
Infection Control Program
Guideline No:
NIPCM – I – 01
Subtitle:
ADMINISTRATIVE COMPONENTS OF THE IPC PROGRAM
Issuing Authority: General Directorate of
Infection Prevention and Control (GDIPC)
Applies To:
All MOH Healthcare Facilities
Effective Date:
April 2016
Page 5 of 5 General Directorate of Infection Prevention and Control
4.3.3. Responsibility of Nursing Representatives or “Link Nurses”:
4.3.3.1. To convey the recommendations of the Infection Control team to the staff of
the ward and send feedback to the Infection Control department.
4.3.3.2. To ensure implementation of infection control activities in the Link Nurses’
department.
4.3.3.3. To be responsible for reporting any infections in the department
4.3.4. Personnel:
4.3.4.1. Epidemiologist
4.3.4.2. Infection Control professionals (doctors & nurses)
4.3.4.3. Environmental officer or ICP
4.3.4.4. Public health officer or ICP
4.3.4.5. Link nurse – nurses from the clinical area
4.3.4.6. IT
4.3.5. Reporting:
4.3.5.1. Administrative: Reports to the Medical Director of the hospital
4.3.5.2. Functional: Report all the required reports (as mentioned above or in the core
components) to the IPC-RD through the Healthcare facility director.
5. Signatories:
APPROVED BY: SIGNATURE
DR. ZEINAB ABBAS SOLTAN, MD Acting Director, Planning and Development General Directorate of Infection Prevention and Control
DR. HAIL M. ALABDELY, MD General Director General Directorate of Infection Prevention and Control