Standards, Rationales, Elements of Performance and Scoring
The IC PROGRAM AND ITS COMPONENTS:
Standard IC. 1. 10
-The risk of development of a health care-associated infection is minimized through a hospital infection control program.
Rational for IC.1.10
-The risk of HAIs exists throughout the hospital. An effective IC program that can systematically identify risks and respond appropriately must involve all relevant programs and settings with the hospital.
Elements of Performance for IC.1.10
1. A hospital IC program is implemented
2. Individuals and/or positions with the authority to take steps to prevent or control the acquisition and transmission of infectious agents are identified.
3. All applicable organizational components and functions are integrated into the IC program.
4. Systems are in place to communicate with licensed independent practitioners, staff, students/trainees, volunteers, and as appropriate, visitors, patients, and families about infection prevention and control issues, including their responsibilities in preventing the spread of infection within the hospital.
5. The hospital has systems for reporting infection surveillance, prevention, and control information to the following:
a. The appropriate staff with the hospital
b. Federal, state, and local public health authorities in accordance with law and regulation
c. Accrediting bodies (see Sentinel Event Reporting, pages SE-8-SE-9, and National Patient Safety Goals, pages APR8-APR10)
d. The referring or receiving organization when a patient was transferred or referred and the presence of an HAI was not known at the time of transfer or referral
6. Systems for the investigation of outbreaks of infectious diseases are in place.
7. Applicable policies and procedures are in place throughout the hospital.
8. Not applicable
9. The hospital has a written IC plan* that includes the following:
a. A description of prioritized risks
b. A statement of the goals of the IC program
c. A description of the hospital’s strategies to minimize, reduce, or eliminate the prioritized risks
d. A description of how the strategies will be evaluated
*Written Plan– a succinct, useful document, formulated beforehand, that identifies needs, lists strategies to meet those needs, and sets goals and objectives. The format of the “plan” may
include narratives, policies and procedures, protocols, practice guidelines, clinical paths, care maps, or combinations of these. *
-The infection control program identifies risks for the acquisition and transmission of infectious agents on an ongoing basis.
Rationale for IC.2.10
-A hospital’s risks of infection will vary based on the hospital’s geographic location, the community environment, the types of programs/services provided, and the characteristics and behaviors of the population served. As these risks change over time- sometimes rapidly- risk assessment must be an ongoing process.
Elements of Performance for IC.2.10
1. The hospital identified risk for the transmission and acquisition of infectious agents throughout the hospital based on the following factors:
a. The geographic location and community environment of the hospital, program/service provided, and the characteristics of the population served.
b. The results of the analysis of the hospital’s infection prevention and control data
c. The care, treatment, and services provided
2. The risk analysis is formally reviewed at least annually and whenever significant changes occur in ant of the above factors
3. Surveillances activities, including data collection and analysis, are used to identify infection prevention and control risks pertaining to the following:
b. Licensed independent practitioners, staff, volunteers, and student/trainees
c. Visitors and families, as warranted
CAMH Refreshed Core, January 2005