Infection Prevention and Control National Infection Prevention and Control Guideline Administrative Components First Edition 2016
National Control Manual 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 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: s are active on three levels: 4.1 (GDIPC) - The regulatory body of 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 Page 1 of 5
National Control Manual 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: Page 2 of 5
National Control Manual 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. Page 3 of 5
National Control Manual 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 (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. Page 4 of 5
National Control Manual 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: DR. ZEINAB ABBAS SOLTAN, MD Acting Director, Planning and Development SIGNATURE DR. HAIL M. ALABDELY, MD General Director Page 5 of 5