Committee and Meetings (Infection Control)

DEPARTMENTAL POLICY AND PROCEDURES INFECTION CONTROL DEPARTMENT Title LOGO COMMITTEE AND MEETIN GS (Infection Control)

Reference No.: Dr. Albar Medical Hospital

Replaces Reference No.:

Applies to: IC Committee Review Date:

Effective Date:

Page ___ of ___

1. PURPOSE a. To establish a system that is well coordinated and organized in order to supervise the infection control activities of the Health Care workers and other ancillary services of Dr. Albar medical Hospital. 2. DEFINITION a. The committee is composed of Heath Care Workers represented by the different departments of the hospital as its members to form the Infection Control Committee. 3. RESPONSIBILITIES ICD STATEMENT OF AUTHORITY  Acting through the Hospital Director, the Infection Control Committee has the authority to: a. Implement the policies and procedures within the hospital in matters of Infection Control. b. It has the authority to investigate potential or real episodes of serious hospital acquired infections and, where necessary, to close wards and redirect patients. c.

It has the authority to formulate the infection control team within the hospital.

d. Education and orientation program for professional staff. e. Surveillance of employees health. f.

Standards of hospital domestic cleaning and food hygiene.

g. Management of visitors in isolation circumstances. h. Establish and supervision of the Infection Control Team. i.

Submit activity report and statistical data to the MOH as required.

 j.

Recommend policies for the prevention of Hospital Acquired Infection and ensure that they are implemented.

k.

Maintain records on surveillance, outbreaks, needle stick injury incidents. These are compiled by the Infection Control Team and come up for discussion during the meetings.

l.

Formulate an antibiotic policy based on the needs of the different specialties and prevalent susceptibility patterns.

m. Implement policies for the safety of health care workers. n. Regulate and give recommendations on any construction or renovation work in the hospital. The plan should be approved by the committee. o. Discuss and find solutions to problems related to infection control encountered by different doctors in their specialties. 4. POLICY a. The Infection Control Committee meeting is chaired by the Hospital Director/Designee. Prepared by:

Approved by:

Reviewed by:

Approved by:

Reviewed by:

Approved by:

   P    M    A    T    S

Title

Reference No:

COMMITTEE AND MEETINGS (Infection Control)

Applies to: IC Committee

b. The Infection Control Committee conducts its meetings ___________________. c.

Members are represented by different departments of the hospital.

d. Each member is issued letters of appointment signed by the Authority. 5. PROCEDURE a. The venue of the meeting me eting is held at the conference con ference room every e very ________________ _______ ___________ _________  _____________________. b. The meeting usually is done for one hour (________ to _________), but extends the times as needed. c.

Pocket of the meeting is given to all members of the committee as soon as statistical reports are ready. Pocket of the meeting will include: i. Agenda ii. Minutes of the previous meeting iii. Nosocomial statistics for the quarterly months. iv. Communicable and Reportable Disease Reports and statistics.

d. Members who cannot attend the meeting should be represented by his/her designee. e. ICC Members i. Hospital Director (ICC Chairman) ii. Assistant Hospital Director iii. Quality Management Director iv. Medical Director v. Chief Operating Officer vi. Chief Microbiologist vii. Nursing Service viii. Pharmacist ix. CSSD and Laundry x. Kitchen xi. OR Supervisor xii. ICU and NICU Head xiii. Housekeeping and Maintenance xiv. Infection Control Director xv. Infection Control Coordinator xvi. Infection Control Practitioners xvii. Safety Committee xviii. Supplies Department xix. Mortuary Department f.

Absence of the members shall be minuted and monitored

g. The ICC secretary will document the minutes of the meeting h. Approved minutes of the meeting is given to the Hospital Supervisor and the ICC Members 6. CROSS REFERENCE 7. FORMS a. Committee Formation order b. Agenda Distribution List c.

Minutes of the meeting (vacant form)

d. Monthly Hospital Nosocomial rates (vacant form) Page ___ of ___

Effective Date:

Review Date

Replaces Policy:

Title

Reference No:

COMMITTEE AND MEETINGS (Infection Control)

Applies to: IC Committee

8. MATERIALS 9. CBAHI REFERENCE STANDARD a. IC. 5, IC, 6 10. REFERENCE a. MOH Infection Control Manual (General Directorate, K.S.A. 1408) b. Hospital Infection Control Manual (Directorate of Medical Education, Thirunanthapuram, Kerala, India)

Page ___ of ___

Effective Date:

Review Date

Replaces Policy: