moh_gov_sa · guide · processed · 400 chunks
المصدره
الشريه المصريه
Ministry of Health
Kingdom of Saudia Arabia
Ministry of Health (MOH)
General Directorate of Infection Prevention and Control (GDIPC)
National Guide for
Auditors in Infection
Control Auditing
Strategies for
Healthcare Facilities
A Standardized Approach
as a Tool for Change
Version 6: January 2025
[Non-Text]
www.moh.gov.sa
#
937
[Non-Text]
SaudiMOH
Tube
MOHPortal
[Non-Text]
SaudiMOH
[Non-Text]
Saudi_Moh
جازقه المصلحه Ministry of Health
In the Name of ALLAH, Most Gracious, Most Merciful
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National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 6-2025
مجله المصلحه
Ministry of Health
ACKNOWLEDGEMENT
is with immense pleasure & enthusiasm that we present the (6th) edition of National guidelines for auditing strategies in health care facilities.
We gratefully acknowledge the valuable contributions and great efforts of all members in the development of these guidelines.
We pray to ALLAH Almighty to grant us strength & guidance to accomplish all goals.
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National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 6-2025
السلامه
Ministry of Health
INTRODUCTION
Preventing harm to patients, health workers and visitors due to infection in health care facilities is fundamental to achieve quality care, patient safety, and the reduction of health care-associated infections (HAls) and antimicrobial resistance (AMR).
Compliance of healthcare facilities in implementing effective infection prevention & control measures is vital for patients, visitors, and staff safety.
Infection Control Audit is a standardized methodology using the uniform explicit criteria to assess the proper implementation of infection prevention & control measures in clinical areas & supportive services within the hospitals.
This manual serves as a guide for auditors to assess the facility in the implementation of infection control standards. Effectively implemented audits provide valuable information for improvement. Therefore, health care requires an increased emphasis on the use of infection control audits to measure the implementation of policies and procedures related to IPC practices.
Infection Control Audit guidelines were designed to ensure uniformity & standardization in measuring the healthcare facilities compliance to infection control standards.
The audit recommendations help to improve compliance to infection prevention and control standards based on national & international guidelines. Therefore, it is essential for healthcare facilities to develop corrective action plan based on audit recommendations and ensure effective implementation.
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National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 6-2025
الجراحه المصلحه
Ministry of Health
TABLE OF CONTENTS
<table><tr><td>Title</td><td>Page #</td></tr><tr><td>Acknowledgement</td><td>3</td></tr><tr><td>Introduction</td><td>5</td></tr><tr><td>ICA Visit Protocols</td><td>7</td></tr></table>
DOAMIN # A
INFECTION PREVENTION & CONTROL ADMINISTRATIVE MEASURES
Page # 11
<table><tr><td>Element # A - 1</td><td>Leadership Support</td><td>11</td></tr><tr><td>Element # A - 2</td><td>Infection Prevention & Control Department</td><td>16</td></tr><tr><td>Element # A - 3</td><td>Infection Prevention & Control Committee*</td><td>23</td></tr><tr><td>Element # A - 4</td><td>Infection Prevention & Control Program</td><td>31</td></tr><tr><td>Element # A - 5</td><td>Infection Prevention & Control Annual Plan</td><td>39</td></tr><tr><td>Element # A - 6</td><td>Infection Prevention & Control Policies & Procedures</td><td>47</td></tr><tr><td>Element # A - 7</td><td>Infection Prevention & Control Education & Training</td><td>52</td></tr></table>
DOAMIN # B
INFECTION PREVENTION & CONTROL KEY MEASURES
Page # 59
<table><tr><td>Element # B - 1</td><td>Hand Hygiene</td><td>59</td></tr><tr><td>Element # B - 2</td><td>Personal Protective Equipment (PPE)</td><td>71</td></tr><tr><td>Element # B - 3</td><td>Isolation Precautions*</td><td>78</td></tr><tr><td>Element # B - 4</td><td>Aseptic Technique</td><td>95</td></tr><tr><td>Element # B - 5</td><td>Single Use Items (SUI)</td><td>115</td></tr><tr><td>Element # B - 6</td><td>Respiratory Protection Program</td><td>117</td></tr><tr><td>Element # B - 7</td><td>Occupational Health Program</td><td>131</td></tr></table>
DOAMIN # C
HAIs SURVEILLANCE & OUTBREAK MANAGEMENT
Page #149
<table><tr><td>Element # C - 1</td><td>Outbreak Management Measures *----</td><td>149</td></tr><tr><td>Element # C - 2</td><td>Emergency Preparedness & Response to National Infectious Diseases’ Threats-</td><td>162</td></tr><tr><td>Element # C - 3</td><td>Antimicrobial Stewardship / Antibiogram*****----</td><td>168</td></tr><tr><td>Element # C - 4</td><td>HAls Surveillance*----</td><td>194</td></tr><tr><td>Element # C - 5</td><td>Patient's Care Bundles for Prevention of HAls & MDROs----</td><td>218</td></tr><tr><td>Element # C 5.1</td><td>Patient's care bundle for prevention of CAUTI----</td><td>219</td></tr><tr><td>Element # C 5.2</td><td>Patient's care bundle for prevention of CLABSI----</td><td>231</td></tr><tr><td>Element # C 5.3</td><td>Patient's care bundle for prevention of VAE----</td><td>245</td></tr><tr><td>Element # C 5.4</td><td>Patient's care bundle for prevention of SSIs----</td><td>256</td></tr><tr><td>Element # C 5.5</td><td>Patient's care bundle for prevention of MDROs----</td><td>265</td></tr><tr><td>Element # C 5.6</td><td>Patient's care bundle for prevention of Dialysis Events. (DE)----</td><td>274</td></tr></table>
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National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 6-2025
جاب المصلحه
Ministry of Health
DOAMIN # D
DEPARTMENTAL INFECTION PREVENTION & CONTROL MEASURES
Page # 286
Element # D - 1 Hemodialysis (HD) Unit---- 284
Element # D - 2 Compound Sterile Preparation (CSP) In Pharmacy*---- 304
Element # D - 3 Operating Room (OR)---- 312
Element # D - 4 Laboratory Department---- 321
Element # D - 5 Dental Services---- 334
DOAMIN # E
SUPPORTIVE SERVICES DEPARTMENTS & RELATED MEASURES
Page #350
Element # E-1 Medical Departmental Stores---- 350
Element # E-2 Dietary Services Department*---- 354
Element # E-3 Laundry Department---- 369
Element # E-4 Mortuary Department---- 376
Element # E-5 Construction & Renovation Measures in Healthcare Facilities---- 383
Element # E-6 Housekeeping & Hospital Environment---- 391
Element # E-7 Disinfectants & Antiseptics Supplies---- 405
Element # E-8 Infectious Medical Waste---- 407
DOAMIN # F
REPROCESSING OF REUSABLE MEDICAL DEVICES
Page #424
Element # F-1 Central Sterilization Services Department (CSSD)*---- 424
Element # F-2 Endoscopy Department*---- 438
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National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 6-2025
الجراحه المصلحه
Ministry of Health
ICA Visit Protocols
Auditing visits are an activity that provides evaluating processes and supporting services to improve the level of infection prevention & control practices within healthcare facilities, and accordingly will prevent or reduce transmission of infection and outbreaks.
Healthcare facilities will be visited according to the plan set for the program. When carrying out any auditing visits, certain protocols are followed to appropriately represent the General Directorate of Infection Prevention & Control (GDIPC) of Healthcare Facilities. Therefore, the specific codes of ethics and professional conduct must be adhered to:
A. Code of Ethics and Professional Conduct
Professional Ethics:
— Commitment to the Ministry of Health's code of ethics and conduct.
— Avoiding any behavior that may be perceived as an abuse of the position.
— During the visit, adhere to professional ethics, and treat others with decency
— and respect.
— Commitment to all professional ethics including avoiding ineffective communication that may cause discomfort to the other party.
— Care must be taken when communicating with all healthcare workers in the facility being visited by exercising self-control and refraining from any disturbing or insulting remarks or actions.
— When the other party exceeds the recognized professional ethics contain the situation with the required respect and report the incident to your supervisor based on the organizational chart.
— Carrying out your work with integrity and diligence.
— Maintaining a professional environment characterized by good working relations and mutual respect.
— Refraining from all verbal and non-verbal violations, including written ones.
— During the visit, your appearance must be professional.
Professional Conduct:
— The auditors should professionally represent the GDIPC in an appropriate manner.
— The auditors must be updated about any new scientific updates including guidelines, forms, and protocol related to their field before conducting any visit.
— The auditor must report any concerns that may affect the quality of the visit before performing it.
— Providing support and guidance to the evaluated healthcare facility colleagues' whether during the visit or afterwards.
— The auditor is responsible for evaluating the performance of the healthcare workers during the visit fairly and realistically, in line with the objectives.
— Guidance given to the hospitals must be based on scientific & best practices basis.
7 | National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 6 - 2025
dajg
Ministry of Health
B. ICA Visit Phases:
Pre Visit Phase:
— The date of the visits should be scheduled during the first five months of each half year.
— 20% of healthcare facilities are scheduled to be visited monthly, provided that the
— different sectors are covered.
— Send the visits schedule to health cluster within the region, in which the date of the visit and the names of the auditors are specified (it is preferable not to visit the same facility by the same auditor within the same year).
— Inform the health cluster to coordinate the visit via e-mail, phone calls or text messages prior to the visit.
— The required number of auditing days are determined according to the healthcare facility bed capacity (two days for hospitals with more than 200 beds and one day to two days for those with less than 200 beds capacity).
— The visit is conducted by two auditors approved by the GDIPC of Healthcare Facilities.
— Cluster auditors are restricted from the audit visits to their cluster hospitals.
— The two auditors should visit all the departments together; they should not divide it between them.
— The auditor must realize his/her responsibilities according to the role assigned during the visit (team leader, auditor, or observer).
— The evaluation form should be sent to the proposed evaluated health cluster and consequently to the healthcare facility in the same cluster before the visit to be review the required documents.
Visit Phase:
— Strict commitment to professional ethics during the visit and represents GDIPC in a professional way.
— Conducting all field visits by evaluating the performance of health care facilities professionally and fairly using the updated auditing form.
— The team must conduct the visit according to the approved schedule and identify all the departments planned to be visited (according to the auditing form), giving the visit the sufficient time needed and not doing it urgently.
— Commitment to the time specified for the visit, whether the working hours or number of days.
— Commitment to the number of team members required and to visit all the departments together.
— Each domain should be evaluated according to the activity required (review document, staff interview, observation, personal file)
— Recommendations should be made based on scientific & evidence basis.
— Auditing scores should be entered at the data collection site using the auditing form according to the approved mechanism and comments must be documented in a clear & precise manner.
— The auditing report must be reviewed before by the team leader prior sending it for the final approval.
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National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 6-2025
الطبيه
Ministry of Health
Post Visit Phase:
— Score and write the audit report then submit it within 72 hours from the physical visit.
— Ensure that the report is delivered to the healthcare facility through the system (download the report from the system and send it via e-mail if submission to facility have been failed).
— Request from the audited health cluster to send their corrective action plan of the evaluated healthcare facility within 7 days from receiving the visit auditing report.
— Ask the health cluster to request from the audited hospital to fill out the auditor's evaluation form, that delivered to them through the system.
— Review the health care facilities action plan that have been sent by the health cluster.
— Follow up the implementation of the action plan by the health cluster and by the auditing coordinator at regional directorate for the visit that took place and if the healthcare facility encounters any challenges or delays, they should support them.
— The Regional Directorate Infection Control Director' should communicate with the Infection Control Director at the health cluster to address the visit and evaluate auditor's performance when needed. (Refer to the Standard Operating Procedure (SOP) of Infection Control Auditing Programs)
For further information, kindly review Standard Operating Procedure (SOP) of Infection Control Auditing Programs V1.0-2024
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National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 6-2025
مجله
الطبحه
Ministry of Health
DOMAIN-A
INFECTION PREVENTION & CONTROL
ADMINISTRATIVE MEASURES
INFECTION PREVENTION & CONTROL MEASURES
HOSPITAL LEADERSHIP SUPPORT
INFECTION PREVENTION & CONTROL DEPARTMENT
INFECTION PREVENTION & CONTROL COMMITTEE
INFECTION PREVENTION & CONTROL PROGRAM
INFECTION PREVENTION & CONTROL ANNUAL PLAN
INFECTION PREVENTION & CONTROL POLICIES & PROCEDURES
INFECTION PREVENTION & CONTROL EDUCATION & TRAINING
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National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 6-2025
الطبيه
الحي
Ministry of Health
Element # A-1
HOSPITAL LEADERSHIP SUPPORT
A - 1.1
Adequate resources are allocated to infection prevention & control department (e.g., offices, internet access, IT support ...etc.) (O, SI)
Observe:
Observation (O)
1. Availability of separate Infection prevention & control (IPC) office with provision of all required resources. (Computers, printers, reliable internet service etc.)
2. The number of computers provided for the IPC department and match with the number of Infection preventoinists working in the unit. (Ideally, each IPC Practitioner has a separate computer with internet connection. But if separate computer not provided for each IPC practitioner, would be considered fully compliant if it's not interfering with continuity of work)
Interview:
1. IPC team if their requests and needs are always considered and provided by leadership personnel and the high officials.
2. The staff about the speed and reliability of internet service and backup plan to ensure the continuity of work if there is no availability of internet service / system is down.
3. Randomly ask staff to access national platform (such as HESN Plus) website to check the speed & reliability of provided internet service.
4. Ask staff about IT support & troubleshooting time i.e., IT department has good response to them when needed.
5. Ask about access to patients & lab data (If hospital has electronic filing system).
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National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 6-2025
الطبيه
Ministry of Health
A - 1.2
Adequate infection prevention & control supplies are provided to HCWs for successful implementation of IPC program (e.g., PPE, disinfectants ...etc.) (D, O, SI)
Review the following documents:
1. Plan for continuous supply of PPE.
2. Inventory checklist for monitoring consumption of all required supplies/consumables.
3. Electronic database / Excel spreadsheets as a mechanism of monitoring consumption of IPC supply & to ensure adequacy.
4. The documented supply chain / flowchart describing mechanism of supply request from units.
5. Review if contingency / emergency plan is incorporated to address the shortage in outbreak situations to ensure continuous supply of PPE, disinfectants & other IPC supply. (e.g., Direct purchase, contract with neighboring hospitals, emergency stock not used in routine etc).
(Rationale: In outbreak situations there is increased consumption of IPC supply including PPE, hand sanitizers, disinfectants etc. so there should be a clear plan to address increased demand in such unforeseen situations).
6. Check the supply chain follow up in the hospital departments especially when the supplies reach the PAR stock level.
(PAR: Periodic Automatic Replenishment)
- PAR level is the minimum quantity of an item stocked, which will be automatically reordered, should the level fall below a preset level.
- Establishing par levels is one of inventory management techniques that ensures amount of inventory that must be available at any given time.
- PAR levels are safety stock numbers that represent the lowest stock level that inventory can reach before a particular item needs to be reordered.
- Ultimately, par levels help to ensure that inventory remains above the standard demand rate.
NOTE:
Any of above-mentioned system or alternate inventory management mechanism/s are acceptable that:
- Ensures continuous uninterrupted availability of IPC supply in all patient care areas.
- Provides platform for regular monitoring of IPC supply consumption in order to ensure adequacy for effective implementation of all IPC programs.
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National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 6-2025
الطبيه
الحي
Ministry of Health
Observation (O)
Staff Interview (SI)
Observe:
✿ Availability of infection prevention & control resources and supplies including PPEs (Gowns (clean, sterile) gloves (clean, sterile) face shields / eye goggles, surgical masks, different sizes of N-95 respirator, disinfectants, hand rub dispensers, waste receptacles, sharp containers etc) in all units.
(Randomly open the PPE trolleys to verify availability of required PPE & hand rub dispenser to check for availability of hand sanitizers & if date is valid or expired.
Interview:
1. Interview the IPC team / supply in charge about the process of replenishment, maintenance, and first-time request of supplies, when and where needed.
2. Investigate the shortage with the person in charge, when it is clearly observed.
3. Ask the staff about the mechanism how the stock will be requested what will be the alternate back up if item is not available in main hospital store.
Example:
In order to ensure availability of all needed infection prevention & control supply for Central line insertion & maintenance, visit the stock rooms in critical care areas (ICU, NICU, ER etc) & randomly ask staff about the availability of IPC supply needed for central line insertions & maintenance practices. e.g Central line insertion kits, chlorohexidine swab sticks, CHG. impregnated transparent dressing, sterile probe covers etc. Assess if enough stock is available or there is any shortage.
Example of Inventory checklist for monitoring:
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National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 6-2025
الطبيه
الحي
Ministry of Health
A - 1.3
Infection prevention & control (IPC) team is given full authority to implement the IPC policies and procedures. (D, SI)
Review the following documents:
- Statement of authority approved by the hospital director or hospital infection control committee.
- This statement of authority should be reviewed and authenticated by the administration of the institution at least every three years or sooner, as per policy.
- All policies & procedures are established by IPC team.
- Check for availability of authority statement or MEMO circulated by highest administrative authority to all units stating authorization of IPC team regarding infection prevention & control practices.
The Director of the Infection Prevention and Control Program has the responsibility and authority to establish policies and procedures for the instruction of its personnel and for the overall supervision of infection prevention and control activities in its facilities.
Interview:
1. IPC Team members if they have been given the appropriate attention & respect by the heads of other departments during daily rounds, training & education activities etc.
2. IPC team regarding the authority to make decisions and to influence field implementation.
3. If the IPC department has been well understood and directly acted upon its comments, remarks, recommendations, and commands.
4. Moreover, heads of the departments are continuously working on IPC improvements & corrective actions if any breach of IPC practice has been communicated to them based on internal & external audit findings.
5. Ask if HCWs simply obey, any order or command coming from the infection prevention & control personnel through any means, even if it is verbal command in matters related to infection prevention & control.
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National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 6-2025
الطبيه
الحي
Ministry of Health
A - 1.4
Hospital leaders' support IPC team and their supervision role when some functions are outsourced (e.g., laundry or dietary services). (D, SI)
Review the following documents:
1: Contract of outsourced service:
- Check for validity and accuracy of contract with clear description of policies of the related outsourced service. (Most common outsourced functions are laundry, dietary service and CSSD in some hospitals etc.)
- For instance, if laundry service is outsourced, check the contract incorporating details of the collection & transportation of the soiled and clean linen including transportation carts, frequency of linen collection, processing of linen with temperature specifications & disinfectants to be used & frequency of inspection visits by hospital IPC team etc.
2: Inspection visit checklists / tools:
- Review the checklist incorporating all details of IPC measures in the relevant outsourced service (Laundry, kitchen etc.) based on the referenced guidelines (MOH, CDC etc.)
- Laundry checklist should contain important items like policies & procedures, direction of workflow, availability of hand hygiene facilities, washing cycles: high temperature wash cycle (Water temperature is at a minimum of 71°C (159.8°F) for 25 minutes: heat disinfection), during low temperature washing cycle, water temperature is at 22°C - 25°C (71°F-77°F)
3: Inspection visit report & action plan:
- Review the last 03 visits reports for all outsourced functions.
- Check if the report was sent to the outsourced service team & they responded with corrective action plan based on the findings of visit report.
Inspection / Audit visit should be conducted to outsourced service/s at least once in each quarter by IPC Team in collaboration with quality & environmental health team.
Interview:
- IPC team with regard to outsourced service hospital policy with its implementation (monitoring of outsourced service by the hospital i.e. process, frequency of visits, etc.)
- Inquire IPC team about needed leadership support if any major breaches has been observed in the outsourced service in repeated visits with no corrective action. (An example of leadership support would be: Hospital directorl CEO would consider change of laundry company or catering company if the quality of processed linen or food quality is not up to the mark even if they have to pay high price).
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National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 6-2025
الطبيه
الحي
Ministry of Health
Element # A-2
INFECTION PREVENTION & CONTROL
DEPARTMENT
A-2.1
For hospitals (≥ 150 beds): the director of IPC department is full-time employee qualified in infection control through certification, training, AND experience for a minimum of two years. (PF, SI)
Review the following documents in PF:
Assignment Letter / Job Description:
1. Verify if the IPC Director is working full time by reviewing assignment letter from executive leadership & job description to review roles and responsibilities of IPC director as full time.
2. Infection Prevention & Control Director will be considered working as FULL TIME in the IPC department only if the below mentioned criteria is fulfilled:
- Available and accessible at all time and dedicate 100% of working hours to infection prevention & control departmental activities.
- IPC Director DO NOT hold any additional administrative tasks (e.g., working as Medical Director & IPC Director etc.)
- ID consultants and Physicians would be considered FULL TIME only if they spend 3 out of 5 working days OR dedicate 70% of working hours to the Infection prevention & control departmental activities with no additional tasks.
CV, certificates & training evidence:
1. The personal file of the IPC director to check for educational background. (Physician, nurse, microbiologist, public health Specialist etc.)
2. Check degrees / certifications in IPC (Masters in Infection Control, CIC, and Diploma in infection Control, etc.)
3. Attendance in training activities (local, national, international conferences, workshops, seminars & symposiums etc.)
4. Calculate total duration of experience in infection control from date of joining as IPC Director. (For IPC director 02 years' experience is required)
5. Experience and training of the IPC director should be relevant to the services provided by the department and the duties and responsibilities of the position.
Comments:
- It is not mandatory for IPC Director to be a physician. If he / she is qualified based on above mentioned credentials and working full time this substandard would be fully met.
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National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 6-2025
arXiv
draft research
Ministry of Health
Interview:
Staff Interview (SI)
1. IPC Director to assess his / her knowledge and skills about infection control.
2. Ask about his/her involvement in development / review of policies and procedures.
3. Ask about role in surveillance activities and implementation of IPC measures to assess his/her orientation about all areas of hospital.
4. Ask how the time is split among data management, policy & procedure development, education, employee health, quality improvement, program development, consulting & managing potential outbreaks etc.
5. During the entire audit visit, knowledge & orientation of IPC director about IPC activities will be indirectly assessed.
A-2.2
For hospitals (< 150 beds): the director of IPC department is a full-time employee qualified in infection control through certification, training, OR experience for a minimum of two years. (PF, SI)
Personal File (PF)
Sub-element - 2:01 & Sub-element - 2:02 have similar assessment methods.
For IPC director of hospitals with bed capacity 150 & below,
certification OR Training OR experience of 02 years is acceptable for the position of IPC director if working full time.
A-2.3
The director of IPC program reports directly to the highest administrative authority (chief executive officer (CEO)). (D) (Updated)
Review:
Document (D)
1. Hospital organogram for the reporting authority of the IPC program director. (Organization chart should clearly delineate that IPC director is directly reporting to highest top management and not to assistants / assigned designees, quality director or any other administrative personnel.)
2. Ask for any Request Letter from Infection Prevention & Control Director & check its addressed to whom. (As per substandard any letter from IPC Director should be directly addressed to highest administrative authority(CEO).
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National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 6-2025
الطبيه
الطبيه
Ministry of Health
A-2.4
The healthcare facility has infection prevention & control staffing ratio of not less than 1 full-time practitioner for every 100 beds assigned merely for the IPC program in order to accomplish the tasks in an effective manner. (D, SI)
Review the following documents:
Document
(D)
Staff Interview
(SI)
A-2.5
Document
(D)
1. IPC department organizational chart.
2. Document stating bed capacity of hospital including emergency beds, dialysis beds / chairs, dental chairs, day cases, and others).
3. Compare number of IPCs with bed capacity and calculate the required number of IPC practitioners as follows:
◆ 001 - 100 beds: 1 IPC practitioner is needed
◆ 101 - 200 beds: 2 IPC practitioners are needed
◆ 201 - 300 beds: 3 IPC practitioners are needed
◆ 301 - 400 beds: 4 IPC practitioners are needed
◆ 401 - 500 beds: 5 IPC practitioners are needed & so on
4. Work schedule of IPC practitioners for the last 3 months to check allocation of IPC practitioners as per requirement in all areas of hospital according to the scope of services.
Interview:
1. Staff about work distribution & responsibilities in the IPC department.
2. Ask about duration of rotation in each assigned unit and daily activities. (e.g., Hand hygiene observations, surveillance activities, monitoring & evaluation, education & training etc.)
A-2.5
An additional one full-time IPC practitioner is staffed for every 30 beds in critical care units (e.g., ICU, PICU, ER, Burn Unit ...etc) assigned merely for the IPC program in order to accomplish the tasks in an effective manner. (D, SI)
Review the following documents:
1. Organizational chart / Organogram of IPC Department.
2. Document showing bed capacity of each critical care unit. (ER, PICU, NICU etc.) Where ventilation and hemodynamic monitoring are routinely performed.
3. Match the requirement of additional IPC practitioners with bed capacity of each critical care unit as follows:
a. < 30 beds: No additional IPC practitioner is needed.
b. 30 - 59 beds: 1 additional IPC practitioner is needed.
c. 60 - 89 beds: 2 additional IPC practitioners are needed.
d. 90 - 119 beds: 3 additional IPC practitioners are needed & so on.
4. Work schedule of IPC practitioners for the last 3 months to check allocation of IPC staffing as per requirement.
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National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 6-2025
الطريقه
Ministry of Health
Staff Interview (SI)
Interview:
1. IPC staffs about work distribution & responsibilities related to critical care units. (Rule out additional assigned tasks other than assigned critical care unit (if any))
2. Ask about duration of rotation in critical care units and daily activities in the assigned unit & how they are managing activities (HAIs Surveillance, Training & education, monitoring and observations etc.
A-2.6
An additional one full-time IPC practitioner is staffed for every 120 dialysis patients per day assigned merely for the IPC program in order to accomplish the tasks in an effective manner. (D, SI)
Review the following documents:
1. Organizational chart / Organogram of IPC Department.
2. Document showing number of dialysis beds / chairs in Hemodialysis Unit.
3. Number of dialysis sessions done per day.
4. Match the requirement of additional IPC practitioner with number of dialysis patients dialyzed each day.
- < 120 dialysis patients per day (1- 119 sessions): No additional IPC practitioner is needed
- 120 dialysis patients per day (120 & above): An additional IPC practitioner is needed
Interview:
1. IPC practitioners about distribution of work and responsibilities in the hemodialysis unit. (Rule out additional assigned tasks other than dialysis unit (if any))
2. Ask about duration of rotation in the dialysis unit and number of dialysis sessions per day and how they are managing activities inside unit (DE Surveillance, training & education, monitoring & evaluation etc.)
NOTE: Full time IPC Practitioner is one who has no additional responsibilities and is exclusively assigned for activities related to infection prevention & control program ONLY.
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National Guide for Auditors in Infection Control Auditing Strategies for Healthcare Facilities: Version 6-2025
الطبيه
الحياء
Ministry of Health
Example 1:
Bed capacity of Hospital “A” = 560
beds
Adult ICU = 45 beds
PICU = 15 Beds
NICU = 30 beds
ER = 20 beds
Hemodialysis unit = 80 beds (Working in 02 shifts) 160 dialysis sessions per day
What is the required number of IPC practitioner?
Refer to sub-elements 2.02, 2.03, & 2.04
Number of IPC practitioner required = Total 09
- 6 for every 100 beds
- 1 additional for adult ICU / 30 Beds
- 1 additional for NICU / 30 beds
- 1 additional for Hemodialysis Unit / 120 dialysis sessions per day
Example 2:
Bed capacity of “hospital B” = 950 beds
Adult ICU = 60 beds
Trauma ICU = 25 beds PICU
= 35 Beds
NICU = 42 beds
ER = 40 beds
Hemodialysis unit = 40 beds (Working in 02 shifts) 80 dialysis sessions per day
What is the required number of ICPs?
Refer to sub-elements 2.02, 2.03, & 2.04
Number of IPC practitioner required = Total 15
- 10 for every 100 beds
- 02 additional for adult ICU / 30 beds
- 01 additional for NICU / 30 beds
- 01 additional for PICU / 30 beds
- 01 additional for ER / 30 beds
A-2.7
Infection prevention & control practitioners are qualified in infection control through certification, training, or experience for a minimum of one year. (PF, SI)
Review the following documents in PF:
Assignment Letter / Job Description:
- Verify if the IPC Practitioners are working full time by reviewing assignment letter from executive leadership & job description to review roles and responsibilities of IPC practitioners as full time.
CV, certificates & training evidence:
- The personal file of the IPC to check for educational background (Physician, nurse, microbiologist, medical technologist, public health Specialist etc.)
- Check degrees / certifications in infection prevention & control (Masters in infection control, CIC, Diploma in infection Control etc.)
- Attendance in training activities (local, national international conferences, workshops, seminars & symposiums etc.)
- Calculate total duration of experience in infection control from date of joining as IPC Practitioner. (For IPC practitioner at least 1 year experience is required)
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الطبيه
الحييه
Ministry of Health
Staff Interview (SI)
Personal File (PF)
Staff Interview (SI)
Interview:
1. IPC Practitioners to assess his / her knowledge and skills about infection control.
2. Ask about their activities in daily IPC rounds.
3. Ask about their role in surveillance activities and methodology of surveillance data collection, CDC-NHSN criteria etc.
4. During the entire audit visit knowledge & orientation of IPC practitioners about IPC activities can be easily assessed.
The IPC Director & IPC Practitioners must have the knowledge and expertise in microbiology, epidemiology, sterilization and disinfection, infectious diseases, antiseptic usage, clinical practices and statistics. The Infection preventionist functions in pivotal roles as educator, investigator, researcher, patient advocate, agent of change, consultant, statistician, sanitarian, role model, coordinator, and diplomat. **
A-2.8
IPC practitioners have updated infection control skills and knowledge through continuous medical education program and attendance in IPC scientific activities. (PF, SI)
Review the following documents in PF:
1. Personal file to check for evidence of attendance in IPC scientific activities. Local, national, international Infection control conferences, workshops, seminars & symposiums etc.) (Check for valid certificates).
2. Departmental continuous educational activities conducted inside the hospital. Check for schedule of CME activities, content delivered and attendance sheets to ensure 100% of IPC staff has attended with competency assessment.
- Professional development is essential to keeping infection preventionsist up to date with the latest knowledge, skills & strategies for preventing infections.
- Competence has been defined as essential knowledge, behaviors & skills that an individual possess and demonstrate in a specific discipline.
- It implies an expert level of knowledge and skill that is transferrable to the practice of Infection prevention & control. (Simply stated, It’ the ability to put knowledge into action)
Interview:
1. IPC Practitioners to assess his / her knowledge and skills about infection control.
2. Ask about their activities in daily IPC rounds.
3. Ask about their role in surveillance activities and methodology of surveillance data collection, CDC - NHSN criteria etc.
4. During the entire audit visit, knowledge & orientation of IPC team about IPC activities can be easily assessed.
Infection Preventionists must acquire skills & knowledge to critically review and understand the scientific evidence regarding infection prevention interventions & engage and educate a diverse group of stakeholders (e.g. Physicians, nurses, lab & radiology technicians, respiratory therapists, environmental services staff & administrators etc.
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الطبيه
جازقه الصحه
Ministry of Health
REFERENCES / WEB BASED RESOURCES:
1) APIC text of Infection Control & Epidemiology: Competency & certification of Infection Perfectionists http://text.apic.org/toc/overview-of-infection-prevention-programs/competency-certification-of-infection-preventionists
2) APIC text of Infection Control & Epidemiology: Staffing http://text.apic.org/toc/overview-of-infection-prevention-programs-staffing
3) APIC text of Infection Control & Epidemiology: Infection Prevention & Control Programs http://text.apic.org/toc/overview-of-infection-prevention-programs/infection-prevention-control-programs-
4) Joint Commission International Accreditation Standards for Hospitals, 5th edition, April 2014. PCI.1
5) Core components for infection control prevention and control programmers Geneva: World Health Organization; 2009 (http://www.who.int/csr/resources/publications/WHO_HSE_EPR_2009_1/en/index.html, accessed 18 October 2016).
6) APIC text of Infection Control & Epidemiology: Education & Training http://text.apic.org/toc/overview-of-infection-prevention-programs/education-and-training
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الطبيه
الحييه
Ministry of Health
Element # A-3
INFECTION PREVENTION & CONTROL COMMITTEE
A-3.1
There is written approved terms of references document for infection prevention & control committee containing structure, rules, duties, and members' responsibilities. (D) (Updated)
Review the terms of reference (TOR) of Infection Prevention & Control Committee meeting and verify the following:
1. TOR are valid and updated (Check for dates)
2. Approved (Check for approvals by top administration)
3. Structure (Composition of IPC committee with inclusion of membership from all relevant units)
The committee consists of multidisciplinary team members.
- Chairman: chief executive officer (CEO).
- Deputy Chairman: Nominated by chairman.
- Committee coordinator.
- Committee secretary.
Permanent Members: included but not limited to:
- Head of Infection Prevention & Control Department
- Head of Nursing Department
- Head of Quality Management & Patient safety
- Head of Critical Care Departments (ICU, NICU, PICU, CCU etc.)
- Head of Obstetrics / Gynecology Department
- Head of Surgery Department
- Head of Operating Room (OR)
- Head of Laboratory (Microbiology)
- Head of Renal Dialysis unit / Nephrology
- Head of Pharmacy Department
- Head of Emergency Medicine (ER)
- Representative from Employee Health Clinic
- Head of Central Sterile Supply Department (CSSD)
- Head of Dietary Services Department
- Head of Environmental Health Department
- Head of Administrative & Financial department
- Infection Prevention & Control Department Members
- Head of Housekeeping / Supportive Services Department"
- Head of Medical Supply / Inventory Management"
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الطبيه
الحي
Ministry of Health
Guest Members:
Chairman & deputy can invite any hospital employee from different departments on an official basis when matters pertaining to their services e.g., Family & community Medicine, dental, supply & logistics etc.
1) Purpose of multidisciplinary committee is:
- To provide oversight of the infection prevention and control program.
- To coordinate, evaluate, and support the activities of the Infection prevention and control program and to communicate with all departments of the healthcare facility to ensure the engagement and full support to the program by all stakeholders.
- The IPC committee advocates for the program shall ensure all resources needed are available.
2) Rules of operations including :(3)
- Frequency of meetings: (Quarterly or as scheduled in hospital, special meetings will be called by chair when circumstances dictate etc).
- Agenda: (All matters to be addressed by the committee should be brought to the attention of the chairperson, Infection preventionists (IP), and/or the appropriate committee members.
- Committee coordinator will prepare the agenda & chairman will sign agenda before distribution to all members.
- Attendance & Quorum: Appointed members are expected to attend and participate in committee activities. 50 - 60% of committee members plus committee chairman/deputy chairman shall constitute quorum of regular & additional meetings.
- Minutes taking: Proceedings of the meetings shall be recorded & prepared by the secretary / IPC coordinator of committee and circulated to all members in a timely manner before next proceeding.
Duties / Functions of IPC Committee : \( ^{(2)} \)
General functions of committee include but not necessarily restricted to the following:
- To ensure that hospital IPC practices meet the requirement of accrediting bodies ICA, CBAHI etc.
- Pursue opportunities to improve patient care and clinical performance.
- Recommend practices to resolve identified infection prevention & control problems in care and performance.
- Recommend corrective actions to governing bodies when necessary.
- Establishes, reviews, and approves the hospital infection prevention and control (IP&C) policies and procedures at least every three years.
- Approve the type and scope of surveillance activities including stratified infection risk, focused infection studies, and prevalence and incidence studies.
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الطبيه
الحي
Ministry of Health
- Determine the amount of time required to conduct infection surveillance, prevention, and control activities.
- Discuss Respiratory Protection Program related activities & measures.
- Evaluates and revises on a continuous basis the procedures and mechanisms developed by the (IP&C) team to serve established standards and goals.
3) Brings to the attention of the (IP&C) any infection prevention & control related issues arising in different departments of the hospital and suggests solutions.
4) Responsibilities of members & attendees:
- Attend at least 75% of meetings having read all agenda & papers beforehand.
- Act as champions disseminating information and good practice as appropriate.
- Identify agenda items to be considered by chair of committee ahead of time.
- If unable to attend send apology to chair and secretary and send designee to attend on their behalf.
- Contribute to discussion and maintain confidences.
A-3.2
Meeting minutes are written in a manner of task force tables with time limit for the actions needed and actions must be followed in the next meeting. (D)
Review the format of meeting minutes:
Check if the standard format is being followed for documenting committee meeting minutes:
a) Meeting minutes of IPC committee should incorporate meeting number, date, time, venue, title, list of attendees, absentees & apologies etc.
b) It should include Agenda / Items, Discussion & Findings, Actions / Recommendations, Responsible Person/s, Time frame & status. (Open / Closed)
c) Agenda would include call to order, review of previous meeting minutes, Infection prevention & control reports (Healthcare-associated infection rates, multi-drug resistant organisms, MRSA rates, any outbreaks, hand hygiene compliance rate, respiratory protection program activities and components etc.), Departmental Infection control Issues & Solutions e.g. delayed release of culture results from microbiology lab etc., Discussion of antibiogram, occupational health issues (e.g. Influenza vaccination refusals etc.), inadequate IPC supply, Issues related to isolation rooms, construction & renovation, outbreaks etc., Adjournment and Closing remarks.
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الطبيه
Ministry of Health
Document
(D)
d) Status of last committee meetings recommendations to be reviewed. (Closed issues to be considered as accomplishments. These accomplishments shall / can be submitted to the management as part of the committee's performance.
e) Issues that are not yet addressed / accomplished to be considered as pending / open issues. These pending issues shall be added as agenda in the old business to find solutions to close the issues. If not, it should be closed as ‘abandoned’, a new alternate solution needs to be in place.
f) If still unresolved need to be escalated to executive committee.
g) Issues discussed in IPC committee meetings are assigned to concerned representatives and should be traceable, timely followed, monitored and evaluated.
h) Discussions, conclusions, recommendations, assignments, actions, and approvals are documented in the minutes of the committee meetings.
i) Minutes are distributed to each committee member and are forwarded to other appropriate staff.
Example:
- Agenda / Items to be discussed: Infection prevention & control surveillance statistics.
- Discussion:
- CLABSI rates in \(3^{\text{rd}}\) Quarter had retained high with average rate of 10.06. CAUTI rate for \(3^{\text{rd}}\) Quarter was 6.24.
- Recommendations /Actions: Strict implementation of infection prevention & control measures during insertion / maintenance and daily necessity review to be intensely implemented and applied by the clinicians to able to reduce occurrence of HAI associated with CLABSI and CAUTI as the committee concluded.
- Responsibilities: Clinicians, nurses, IPC practitioners
- Time frame: October - December 2021
- Status: Closed
Procedure:
- Committee members will identify agenda items for consideration by the chairman, coordinator / secretary at least 12 days before the meeting.
- All matters to be addressed by the committee should be brought to the attention of the chairperson, Infection Preventionists (IP), and / or the appropriate committee members.
- The committee chairman shall instruct to include these issues / recommendations in the next agenda for discussion.
- Committee coordinator will prepare the agenda.
- Chairman will sign the agenda before distributing to all member's prior the time of the meeting.
- Chairman requests from members to discuss the new agenda, to update committee on previous agenda / matters and present report to the committee.
- Committee meets quarterly or as scheduled in the hospital.
- Discussions, conclusions, recommendations, assignments, actions, and approvals are
Document
(D)
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الطبيه
الحي
Ministry of Health
documented in the minutes of the committee meetings by IPC coordinator/secretary.
- The minutes should be approved & signed by chairperson of the committee. i.e. Hospital Director.
- The minutes shall be distributed after to all committee members and forwarded to all relevant staff.
- Minutes of each committee meeting shall be maintained in a permanent separate file.
- Committee annual report on yearly performance to be developed and distributed.
A-3.3
IPC committee is chaired by the chief executive officer (CEO). (D) (Updated)
A-3.4
Membership of IPC committee includes head of IPC, IPC department members, medical director, head of nursing services, head of laboratory department (microbiology), head of surgical operating room, head of CSSD, head of critical care units (ICUs), head of pharmacy department, head of dietary services, head of environmental health department, head of housekeeping department, head of administrative or financial department, head of medical supply department, and other guest members as needed. (D)
Review the following documents:
TOR, Meeting minutes & attendance sheets:
- Check the meeting minutes with attendance sheets of last 03 committee meetings for purpose of verification.
- Review team composition with multidisciplinary involvement to verify if matching with composition / structure of IPC committee members as described in Terms of Reference. (Refer to composition under sub element 1)
- Verify that the committee is chaired by hospital director (i.e., committee’s chairman name should be reflected in term of reference and meeting minutes.
- Issues discussed in IPC committee meetings are assigned to concerned representatives and should be traceable and timely closed.
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الطبيه
Ministry of Health
A-3.5
IPC committee meets on a regular basis (at least quarterly) or when required on urgent demand. (D)
Review the following documents:
IPC committee meetings minutes to verify if the committee is meeting on regular basis (at least each quarter) and when needed. (Review at least last 03 previous meeting minutes).
The Chair can call special meetings when circumstances dictate.
a) Check the dates and attendance sheet to see the presence of 50% Quorum as mentioned in the TOR.
* 50% of Committee members + Committee chairman / deputy chairman shall constitute a quorum of regular & additional meetings.
* If the Quorum is not met (i.e., attendance falls below 50% level of any meeting), the meeting must be rescheduled upon discretion of chairman.
- Review meeting minutes of any urgent IPC committee meeting held in the previous months.
- Urgent IPC committee meetings must be conducted to address emergency / contingency situations like any National Infectious Diseases' Threats, HAI outbreaks or any other urgent issues affecting the patient safety.
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الطبيه
الطبيه
Ministry of Health
A-3.6
Functions of IPC committee include, but not limited to: (revision and evaluation of the IPC yearly plan, review and approval of IPC policies & procedures, review of surveillance data, & discuss respiratory protection program related activities & measures, etc). (D, SI)
Review the following document:
- Review Infection Prevention and Control Committee term of reference (TOR) and meeting minutes to ensure incorporating functions as highlighted below. **
- Review the meeting minutes to check the content / issues discussed in past 03 meetings and check the status.
Functions include: **
A. Review of the hospital infection prevention and control policies and procedures. (Check if hospital infection prevention and control policies and procedures manual was approved and signed by the committee members after thorough discussion and any required revision.)
B. Review the meeting minutes & check if healthcare associated infections surveillance data was presented and discussed by the infection prevention and control team with corrective interventions.
(Rate of HAI should be tracked and followed meticulously in the committee, AND the members should always suggest and agree - upon the appropriate actions.)
C. Check if annual Infection control plan was presented by infection prevention and control team with suggestion of additions/changes if necessary and eventual approval of Annual IPC plan.
D. Evaluates and revises on a continuous basis the policies & procedures & the developed by the infection prevention & control team to serve established standards and goals.
E. Each member of the committee acts as an advocate of infection prevention & control in his department, trying to promote its principles, and ensures application of its rules. (Refer for more functions to Reference 1,2)
F. Review the last committee meeting minutes and check if respiratory protection program was introduced and discussed in details.
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الطبيه
الحي
Ministry of Health
Interview:
1) At random members of Infection Prevention & Control Committee representatives during rounds (ICU, OR, ER etc.) to assess if they are aware and well informed about the functions of infection control committee, frequency of meetings etc.
2) Ask how they are acting as an advocate of infection prevention & control in his / her department, trying to promote its principles, and ensures application of its rules. (e.g encourage HCWs to comply with infection prevention & control policies and procedures in their respective units.)
Example:
- High CLABSI rate in NICU was presented as urgent issue in last infection control committee meetings by IPC department.
- Causes of high CLABSI rate and major issues were discussed with proposed corrective actions & approval of CLABSI improvement project for NICU.
- Head / Representative from NICU & other team members in NICU should be aware of PIP as implementations would be executed through them as per suggested solution in IPC committee meeting.
3) Ask if committee representatives were aware about HAIs (CLABSI, CAUTI, VAE, SSI, and MDROs) & Hand hygiene trends projected in last committee meetings concerning their units and actions taken to reduce them. (VAE rate in ICUs & implementation of care bundles, SSI rates and SSI bundle compliance, hand hygiene compliance rates, respiratory protection program activities etc.)
4) Ask if they face any new issue related to infection prevention & control in their unit / area, how they are addressing it?
Any new infection prevention & control issue must be brought to the attention of the infection prevention & control team & communicated to committee chairperson for discussion in the IPC Committee with suggested solutions.
REFERENCES / WEB BASED RESOURCES:
1) Ministry of Health: Guidelines for Infection Control Committee Terms of Reference. pdf (03-2023).
2) Core components for infection control prevention and control programmes.
Geneva: World Health Organization; 2009 (http://
www.who.int/csr/resources/publications/WHO_
HSE_EPR_2009_1/en/index.html, accessed 18 October 2016).
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الطبيه
Ministry of Health
Element # A- 4
INFECTION PREVENTION & CONTROL PROGRAM
A-4.1
There is a program to reduce the risk of healthcare associated infections (HAls) that involves patients, staff, trainees, volunteers, families, and visitors. (D, SI)
Infection Prevention & Control — is the discipline / process by which health care facilities develop and implement specific policies and procedures to prevent the spread of infections among health care staff and patients.
Healthcare-associated Infections (HAIs) — Healthcare-associated infections (HAIs) are infections that patients can get in a healthcare facility while receiving medical care. These infections are often preventable. (9)
An Infection Prevention and Control (IPC) program is the most important component of safe, high-quality health service delivery. IPC program implemented in the hospital is critical not only to prevent HAIs but also to prepare for and respond to communicable diseases crises. \( ^{(4)} \)
IPC program with a dedicated, trained team should be in place in each acute health care facility for the purpose of preventing HAI and combating AMR through IPC good practices. \( ^{(3)} \)
Purpose of IPC program is to eliminate the risk of HAIs and work-related infections within the healthcare facility through the implementation of established guidelines and policies.
Hospital Acquired Infections are one of the most common complications or adverse events affecting patients and health care workers. They result in increased morbidity and mortality and impact on the capacity of health systems to function effectively. HAI also increase health care costs and can result in the increased usage of antimicrobial agents, thereby fueling the problem of AMR. In 2011, WHO reported that 7% of patients in developed and 10% in developing countries will acquire at least one HAI at any given time. \( ^{(4)} \)
According to the Centers for Disease Control and Prevention (CDC), 1 in 25 hospitalized patients will get an infection because of the care they receive. An estimated 75,000 patients will die each year.
Because HAIs are a threat to patient safety, hospitals and healthcare facilities need to implement an efficient, comprehensive infection prevention & control program to ensure patients, staff & visitors safety. These interventions have led to an increased focus in prevention efforts, as well as improvements in clinical practice and medical procedures. \( ^{(9)} \)
IPC teams need to incorporate a set of essential core components to help plan, organize and implement an IPC programme. \( ^{(4)} \)
These core components, together with their constituent elements, should be implemented in line with the priorities of the IPC programme and the resources available and adapted to both national and healthcare facility level \( {}^{(4)} \)
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الطبيه
الحي
Ministry of Health
Review:
Hospital's infection prevention & control program incorporating following core elements included but not limited to:
- Program Introduction
- Goals, Mission & Vision of IPC Program: Goals of the infection prevention & control program need to be incorporated into the mission statement of the facility. A mission statement should tell who you are, what you do, and should communicate a clear view of purpose and set a strategy for accomplishing the goals e.g. “Our mission is to promote a healthy and safe environment by preventing transmission of infectious agents among patients, staff and visitors”
- Organizational structure of the IPC program (IPC staffing & responsibilities)
- Infection Prevention & Control Committee
- Scope of service: Activities performed by the prevention and control of Infection department members fall with updated Infection control standards and these include the following:
a. Surveillance of Healthcare associated infections & Antimicrobial Resistance (AMR). \( ^{2} \)
b. IPC activities related to patients, visitors and health care workers' safety and the prevention of AMR transmission. (Hand hygiene program, respiratory protection program, Employee health Program etc.
c. Development or adaptation of guidelines and standardization of effective preventive practices (standard operating procedures) a
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