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Guide to HIQA’s targeted monitoring
programme against the National Standards
for the prevention and control of healthcare-
associated infections in acute healthcare
services during the COVID-19 pandemic
September 2020
Guide to HIQA’s targeted monitoring programme against the National Standards for the prevention and control of
healthcare-associated infections in acute healthcare services during the COVID-19 pandemic
Health Information and Quality Authority
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Guide to HIQA’s targeted monitoring programme against the National Standards for the prevention and control of
healthcare-associated infections in acute healthcare services during the COVID-19 pandemic
Health Information and Quality Authority
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About the Health Information and Quality Authority (HIQA)
The Health Information and Quality Authority (HIQA) is an independent statutory
authority established to promote safety and quality in the provision of health and
social care services for the benefit of the health and welfare of the public.
HIQA’s mandate to date extends across a wide range of public, private and voluntary
sector services. Reporting to the Minister for Health and engaging with the Minister
for Children and Youth Affairs, HIQA has responsibility for the following:
Setting standards for health and social care services — Developing
person-centred standards and guidance, based on evidence and international
best practice, for health and social care services in Ireland.
Regulating social care services — The Chief Inspector within HIQA is
responsible for registering and inspecting services for older people and people
with a disability, and children’s special care units.
Regulating health services — Regulating medical exposure to ionising
radiation.
Monitoring services — Monitoring the safety and quality of health services
and children’s social services, and investigating as necessary serious concerns
about the health and welfare of people who use these services.
Health technology assessment — Evaluating the clinical and cost-
effectiveness of health programmes, policies, medicines, medical equipment,
diagnostic and surgical techniques, health promotion and protection activities,
and providing advice to enable the best use of resources and the best
outcomes for people who use our health service.
Health information — Advising on the efficient and secure collection and
sharing of health information, setting standards, evaluating information
resources and publishing information on the delivery and performance of
Ireland’s health and social care services.
National Care Experience Programme — Carrying out national service-
user experience surveys across a range of health services, in conjunction with
the Department of Health and the HSE.
Guide to HIQA’s targeted monitoring programme against the National Standards for the prevention and control of
healthcare-associated infections in acute healthcare services during the COVID-19 pandemic
Health Information and Quality Authority
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Contents
Section 1: Overview ............................................................................................. 5
1.1 Introduction ................................................................................................ 5
1.2 Aim of this programme ................................................................................ 5
1.3 The purpose of this guide ............................................................................ 6
1.4 General queries in relation to this programme ............................................... 6
Section 2: How HIQA will inspect through this monitoring programme ..................... 7
2.1 Inspection teams ......................................................................................... 7
2.2 Before an inspection .................................................................................... 7
2.3 Public health precautions during inspection ................................................... 7
2.4 On-site fieldwork ......................................................................................... 8
2.5 The day of inspection .................................................................................. 8
2.6 Documentation, data and information request ............................................... 9
2.7 Confidentiality ............................................................................................. 9
2.8 Meetings ................................................................................................... 10
2.9 Clinical area inspections ............................................................................. 10
2.10 Close-out meeting ................................................................................... 10
2.11 Risk management and escalation .............................................................. 11
2.12 HIQA’s inspection report .......................................................................... 11
2.13 Freedom of Information ........................................................................... 13
Section 3: National Standards ............................................................................. 14
3.1 Quality and safety ..................................................................................... 15
3.2 Capacity and capability .............................................................................. 15
3.3 Standards for review under this monitoring programme ............................... 15
Section 4: Guidance for assessment judgment framework..................................... 17
4.1 Assessment judgment framework ............................................................... 17
Bibliography ....................................................................................................... 25
Appendix 1 Sample documentation and data request for review on the day of
inspection .......................................................................................................... 26
Appendix 2 HIQA’s Risk Escalation process .......................................................... 29
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Section 1: Overview
1.1 Introduction
Under the Health Act 2007, Section 8(1) (c) confers the Health Information and
Quality Authority (HIQA) with statutory responsibility for monitoring the quality and
safety of healthcare among other functions. In light of the ongoing global pandemic
of COVID-19, HIQA has developed a monitoring programme to assess compliance
against the National Standards for the prevention and control of healthcare-
associated infections in acute healthcare services during the COVID-19 pandemic.
The national standards provide a framework for service providers to assess and
improve the service they provide particularly during an outbreak of infection
including COVID-19.
This focused monitoring programme against the National Standards for the
prevention and control of healthcare-associated infections in acute healthcare
services is designed to complement, but run separately from, HIQA’s existing
programmes:
monitoring against National Standards for Infection Prevention and Control in
Community Services (rehabilitation and community inpatient healthcare
services) during the COVID-19 pandemic
regulation of medical exposure of ionising radiation
registration and regulation of designated centres in accordance with Section
41 of the Act.
This guide document should be applied in conjunction with the following:
National Standards for the prevention and control of healthcare-associated
infections in acute healthcare services (2017)
Assessment judgment framework for monitoring compliance against the
National Standards for the prevention and control of healthcare-associated
infections in acute healthcare services (2020)
The Health Act 2007 (as amended).
1.2 Aim of this programme
The aim of this focused inspection programme is to promote improvement in the
management of infection prevention and control. The programme will monitor
compliance with specific national standards for infection prevention and control in
Guide to HIQA’s targeted monitoring programme against the National Standards for the prevention and control of
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acute hospitals, with a focus on the ongoing COVID-19 pandemic and its
management in acute hospitals.
1.3 The purpose of this guide
This guide provides information to service providers on the national standards that
will be monitored by inspectors and should also be used by service providers to self-
assess their own service.
1.4 General queries in relation to this programme
General queries or questions in relation to this programme or the information
contained within this guide can be sent by email to [email protected].
Such queries will be referred to a member of the Healthcare Team involved in the
programme for reply. It should be noted, however, that specific queries about an
inspection can only be accepted from the manager in overall charge of the hospital.
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Section 2: How HIQA will inspect through this monitoring
programme
The following section of this report outlines the specifics of how HIQA will conduct
each inspection and progress to the publication of individual inspection reports under
this programme of monitoring. Further detail of what HIQA will be assessing against
the national standards is outlined in Section 3 of this document.
2.1 Inspection teams
Inspection teams comprise HIQA staff who have been appointed by HIQA as
Authorised Persons under the Health Act 2007, and work within the powers described
in the Act to monitor compliance with standards. Inspectors are obliged to comply
with HIQA’s Code of Conduct for staff, which is available at www.hiqa.ie.
2.2 Before an inspection
HIQA will review key pieces of information relating to the way the service is
organised and operated. Key pieces of information include:
information from previous HIQA inspections
relevant unsolicited information received by HIQA in relation to the service.
2.3 Public health precautions during inspection
Inspectors will take all necessary precautions, in line with public health advice to
reduce risks associated with COVID-19. This will include:
the observation of physical distancing at all times throughout the inspection
the monitoring by HIQA of symptoms of COVID-19 in inspectors, including
checking temperature prior to entering a hospital
a declaration by the inspector to the person with overall responsibility for the
hospital that they have no symptoms of illness or a raised temperature
the observation of good hand hygiene at all times
compliance with respiratory hygiene and cough etiquette by inspectors at all
times
the appropriate use of personal protective equipment in accordance with HSE
guidance and any national recommendations
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compliance with any additional measures hospitals have in place as
appropriate.
Furthermore, inspectors will be familiar with the most recent guidance and guidelines
from the Health Service Executive (HSE) and the Health Protection Surveillance
Centre (HPSC).
2.4 On-site fieldwork
Inspections may be unannounced (the hospital will not receive any prior
notification of the date of an inspection) or short-term announced (where 48 hours’
notice prior to inspection will be provided). Inspections will generally be performed
within core working hours. At the beginning of the inspection, inspectors will
introduce themselves, outline the purpose and duration of the inspection to the
person with overall responsibility for the hospital.
Information will be gathered by the inspection team through:
speaking with management, staff and patients. Meetings will be held in line
with guidance on physical distancing. Where physical distancing cannot be
maintained, appropriate personal protective equipment will be worn by
inspectors in line with public health guidance
reviewing documents and data to determine if appropriate records are kept
and reflect practice
observing clinical environments.
2.5 The day of inspection
On arrival at the hospital, the inspection team will meet with the person with overall
accountability and responsibility for the hospital, for example, the chief executive
officer or general manager. Hospitals will be asked to nominate a liaison person who
will be responsible for engagement with HIQA during the course of the inspection.
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Table 1. Sample one-day unannounced/announced inspection schedule
During the inspection, inspectors will:
Request access to a secure room (ideally where physical distancing can be
maintained) for the purpose of interviews and documentation review.
Request visitor name badges or door access cards to facilitate movement
throughout the service. These should be made available to the inspection
team as soon as possible following arrival onsite and will be returned at the
end of the inspection.
Ascertain if access to clinical areas are restricted, for example, for health and
safety reasons.
2.6 Documentation, data and information request
HIQA will request documentation, data and information on the day of inspection and
will review the documentation and data provided (Appendix 1).
2.7 Confidentiality
In line with current data protection legislation, HIQA requests that unless specifically
requested to do so, services do not send named patient information or information
Close out meeting
Review of documentation
Clinical areas inspections
Meetings:
1. Infection Prevention and Control Team
2. CEO/ General Manager
3. Clinical Director
Meet with the manager in overall charge
Arrive on site for announced/unannounced inspection
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that could identify an individual patient to HIQA by email or by post. Hard copy
documents provided to inspectors for removal from the service should not contain
data that identifies individual patients.
2.8 Meetings
The inspection team will arrange a time to meet with key personnel. Meetings will be
held with, for example:
infection prevention and control team member or members
the person with overall responsibility for the hospital on the day of inspection
the clinical director
the clinical nurse manager or nurse in charge in the inpatient ward or wards.
The purpose of the meetings is to gather information about:
how the service is led and managed
how risks are identified and managed
how the management team is assured that the service provided is safe and
effective.
2.9 Clinical area inspections
The inspection team will visit inpatient wards or units and gather information in
relation to the management of and oversight arrangements to ensure prevention and
control of infection and outbreak management.
The inspection team will use specific monitoring tools to gather information about
the management and oversight arrangements. Monitoring tools are aligned to the
national standards, HSE standards and guidance, relevant legislation and
recommended best practice guidance. It should be noted that these tools have been
specifically designed for HIQA monitoring purposes only.
2.10 Close-out meeting
When the inspection has been completed, the inspection team will conduct a close-
out meeting with the manager with responsibility for the hospital. The purpose of
this meeting is to provide preliminary findings of the inspection and identify any high
risks which require immediate action and to allow management address such risks.
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2.11 Risk management and escalation
HIQA takes a risk-based approach to monitoring. This approach informs how
frequently HIQA will inspect any individual service. It also informs the nature,
intensity and the type of inspection carried out.
Risk identified by HIQA during this monitoring programme will be escalated to the
manager in overall charge in line with HIQA’s risk management process:
High risks identified during a service inspection which require immediate
mitigation will be brought to the attention of the manager in overall charge
during the inspection. This is to allow them to immediately implement the
actions necessary to mitigate such risks.
Formal written notification of any identified risk arising during this monitoring
programme will be issued to the manager in overall charge by email within
two working days of identifying the risk; with the requirement to formally
report back to HIQA stating how the risk has been mitigated within a further
two working days. (Appendix 2)
In the case of high risks whereby immediate mitigation may not be reasonably
achievable, formal notification of the identified risk will be issued to the
manager in overall charge by email within two working days of identifying the
risk; with the requirement to formally report back to HIQA with an action plan
to reduce and effectively manage the risk within five working days of receiving
correspondence from HIQA. This letter will outline the identified risks and,
where required, will inform the accountable person that another unannounced
monitoring assessment will take place within six weeks of first inspection. This
is to allow them mitigate against identified risks.
2.12 HIQA’s inspection report
An individual report will be generated for each service inspected. Inspection reports
will be published on HIQA’s website at www.hiqa.ie.
Each report will outline HIQA’s findings including areas of good practice and any
identified opportunities for improvement. The report will include risks, if any, that
were identified during the monitoring process and may include correspondence
between HIQA and the manager in overall charge in relation to the management of
such risk. As such, HIQA requests that the hospital does not include individual staff
names in return correspondence.
In 2019, HIQA revised its approach to the receipt of feedback from services on
reports progressing through the drafting process. Under this new and enhanced
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process, each inspection report goes through three main stages as they are prepared
for publication.
Stage 1 inspection report
A stage 1 inspection report will be issued with a feedback form, by email, to the
manager in overall charge.
Preliminary findings will have been given during the close-out meeting. However,
following review of the stage 1 report the manager in overall charge can return the
feedback form to include any factual accuracy detail along with feedback on receipt
of the stage 1 inspection report.
The manager in overall charge is encouraged to engage with the lead inspector if
deemed necessary and in advance of completion of the formal written
documentation, to discuss specific concerns or queries they may have regarding the
judgments in this stage 1 inspection report. This can be completed by phone and or
email.
To complete the feedback process, and having engaged as necessary via telephone
or email with the lead inspector, if deemed necessary, the manager in overall charge
should formally complete the factual accuracy and feedback form provided with the
draft report, and return this to HIQA within 15 working days of receipt.
Stage 2 inspection report
On receipt of feedback from the service on a stage 1 report, HIQA will consider the
feedback in the context of evidence gathered on inspection. Consequently, a stage 2
inspection report will be produced which will include any required amendments made
by the inspector resulting from the feedback process. This stage 2 report will then be
again issued to the service for review.
If the manager in overall charge believes that the judgment or judgments contained
in the stage 2 inspection report are not based on the evidence made available to
inspectors at the time of the inspection, or if they believe that the judgment(s) are
disproportionate to the evidence reviewed, they may decide to make a formal
submission to HIQA to challenge a regulatory judgment or judgments contained in
the stage 2 report.
Should a manager in overall charge decide to make a submission, this must be made
within 10 working days of receipt of the stage 2 report. The process for
making a formal submission is detailed below. Should 10 days elapse without receipt
of submission on a regulatory judgment, reports will proceed to stage 3 and
publication as outlined below.
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Stage 3 inspection report
A stage 3 inspection report is issued to the manager in overall charge prior to
publication. The stage 3 report is the version of the report that will be published and,
if a submission has been received, the stage 3 inspection report will have taken into
consideration any decisions of the Submissions Decision Panel.
The stage 3 inspection report will be sent to the manager in overall charge five
working days before publication. A copy of the draft report will also be sent to
other relevant personnel as formally agreed with the HSE and Department of Health.
HIQA’s revised submission policy 2019
The manager in overall charge can make a formal submission if they believe that the
judgment(s) contained in the stage 2 inspection report are not based on the
evidence made available to inspectors at the time of the inspection or the
judgment(s) are disproportionate to the evidence reviewed.
As part of this process, the manager in overall charge may formally submit
comments, evidence or descriptors of circumstances that supports their case.
A service wishing to make a submission on a regulatory judgment must first engage
in the feedback process with the lead inspector as described in the section ‘Stage 1
inspection report’ above.
Further information on HIQA’s submissions procedure and how to make a submission
can be found on the HIQA website (www.hiqa.ie).
2.13 Freedom of Information
HIQA is subject to the Freedom of Information Acts and the statutory Code of
Practice regarding Freedom of Information.
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Section 3: National Standards
The National Standards for the prevention and control of healthcare-associated
infections in acute healthcare services (2017) were developed using an established
framework for the development of all national standards.
Figure 1 illustrates the eight themes under which these standards are presented. The
four themes on the upper half of the circle relate to quality and safety in a service,
while the four on the lower portion of the circle relate to the key areas of a service’s
capacity and capability. The National Standards for the prevention and control of
healthcare-associated infections in acute healthcare services (2017) can be accessed
on the HIQA website - www.hiqa.ie
Figure 1 Themes in the National Standards for the prevention and control
of healthcare-associated infections in acute healthcare services
The national standards are organised into two dimensions:
1. Quality and safety
2. Capacity and capability
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3.1 Quality and safety
The four themes of quality and safety are:
Person-centred Care and Support — how acute healthcare services
communicate with patients to ensure they are well informed, involved and
supported in the prevention, control and management of healthcare-associated
infections throughout their care pathway.
Effective Care and Support — how acute healthcare services effectively plan,
organise and manage infection prevention and control efforts to achieve best
possible outcomes for patients.
Safe Care and Support — how acute healthcare services support a culture of
patient safety through effective management of risks and healthcare-associated
infection incidents and by promoting change and improvement in infection
prevention and control practices.
Better Health and Wellbeing — how acute healthcare services work in
partnership with patients, families and visitors to promote and enable safe infection
prevention and control practices.
3.2 Capacity and capability
Delivering improvements within these safety and quality themes depends on
service providers having capacity and capability in the following four key areas:
Leadership, Governance and Management — the arrangements put in place
by a service for accountability, strategic decision-making and performance
assurance, underpinned by integrated communication and reporting networks
among staff.
Workforce — how acute healthcare services ensure enough staff are available at
the right time with the right skills and expertise to meet the service’s infection
prevention and control needs.
Use of Resources — how acute hospitals plan, manage and prioritise their
resources to meet the service’s infection prevention and control needs.
Use of Information — how acute healthcare services ensure the integration,
availability and protection of all information sources necessary to provide safe and
effective infection prevention and control practices.
3.3 Standards for review under this monitoring programme
This section of the guide will outline the six key National Standards for the
prevention and control of healthcare-associated infections in acute healthcare
services (2017) selected for review for this inspection programme. Only those
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national standards which are relevant to the focus of the inspection will be included
under the respective theme.
The lines of enquiry for this monitoring programme of infection prevention and
control in acute hospitals will focus on six specific national standards within four of
the eight themes of the standards, spanning both the capacity and capability and
quality and safety dimensions. Acute hospitals should always aim to comply with all
the national standards for infection prevention and control.
Guidance under each individual standard is presented in the following section. Each
standard will describe what a service meeting this standard looks like.
These are set out in more detail in the following sections of this document.
Capacity and capability dimension
Theme: Leadership Governance and Management
Standard 5.3 Service providers have formalised governance
arrangements in place to ensure the delivery of safe and effective
infection prevention and control across the service.
Theme: Workforce
Standard 6.1. Service providers plan, organise and manage their
workforce to meet the services’ infection prevention and control needs.
Quality and safety dimension
Theme: Effective care and support
Standard 2.6: Healthcare is provided in a clean and safe physical
environment that minimises the risk of transmitting a healthcare-
associated infection.
Standard 2.7: Equipment is cleaned and maintained to minimise the risk
of transmitting a healthcare–associated infection
Theme: Safe care and support
Standard 3.1: Service providers integrate risk management practices
into daily work routine to improve the prevention and control of
healthcare-associated infections.
Standard 3.8: Services have a system in place to manage and
control infection outbreaks in a timely and effective manner.
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Section 4: Guidance for assessment judgment framework
HIQA is responsible for assessing whether the service provider is in compliance with
the national standards under Section 8 1 (c) of the Health Act 2007 as amended.
In order to carry out its functions as required by the Health Act 2007 as amended,
HIQA has adopted a common Authority Monitoring Approach (AMA). All HIQA staff
involved in the regulation of services or the monitoring of services against standards
are required to use this approach and any associated policies, procedures and
protocols. HIQA’s monitoring approach does not replace professional judgment.
Instead, it gives a framework for staff to use professional judgment and supports
them to do this. The aim of AMA is to ensure:
a consistent and timely assessment and monitoring of compliance with
regulations and standards
a responsive and consistent approach to regulation and assessment of risk
within acute hospitals
contribute to the improvement of the service being inspected through
application of the inspection process.
In order to improve the quality and safety of healthcare services, service providers
are encouraged to continually seek improvements in the services they provide to
patients admitted to these hospitals.
4.1 Assessment judgment framework
The inspection team will use an assessment judgment framework to guide them in
assessing and judging a service’s compliance with the national standards. It sets out
the lines of enquiry to be explored by inspectors in order to assess compliance with
the standards being monitored or assessed. Once an inspector has gathered and
reviewed evidence from a service, they will make a judgment on how the service
performed. The following judgment descriptors will be used:
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Compliant Substantially compliant
Partially compliant
Non-compliant
A judgment of compliant means that on the basis of this inspection, the service is in compliance with the relevant national standards.
A judgment of substantially compliant means that the service met most of the requirements of the national standards but some action is required to be fully compliant.
A judgment of partially compliant means that the service met some of the requirements of the relevant national standard while other requirements were not met. These deficiencies, while not currently presenting significant risks, may present moderate risks which could lead to significant risks for patients over time if not addressed.
A judgment of non-compliant means that this inspection of the service has identified one or more findings which indicate that the relevant standard has not been met, and that this deficiency is such that it represents a significant risk to patients.
Capacity and capability
This section focuses on the overall delivery of the service and how the provider is
assured that a quality, safe and effective service is provided to people admitted to
acute hospitals.
It includes how the service provider:
is assured that there are effective governance structures and oversight
arrangements in place for clear accountability, decision-making, risk
management and performance assurance. This is underpinned by effective
communication among staff. This includes how responsibility and
accountability for infection prevention and control is integrated at all levels of
the service.
plans, manages and organises their workforce to ensure enough staff are
available at the right time with the right skills and expertise to meet the
service’s infection prevention and control needs.
ensures that the necessary resources are in place to to meet the service’s
infection prevention and control needs.
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For the purpose of this inspection, inspections will monitor compliance in relation to
the following themes and standards.
Theme: Leadership Governance and Management
Standard 5.3: Service providers have formalised governance arrangements in
place to ensure the delivery of safe and effective infection prevention and control
across the service.
What a service meeting this standard looks like:
Corporate and clinical governance arrangements that outline clear roles,
responsibilities and reporting-up-and-down processes for the prevention and
control of healthcare-associated infections at all levels of staff throughout the
service are in place.
Governance arrangements ensure that effective infection prevention and control
and antimicrobial stewardship programmes are in place, with the required
resources to implement them.
Corporate and clinical governance arrangements are integrated to ensure that
those staff with specialist expertise, who can evaluate and advise on the
management of infection prevention and control risk, report directly to those with
operational management responsibility and authority to actively address these
risks.
Services have developed and operate pathways to treat both patients with COVID
and without COVID simultaneously.
A mechanism is in place to ensure that the indicators selected to assess the
service’s performance in the prevention and control of healthcare-associated
infections and antimicrobial stewardship provide an accurate level of assurance.
The people involved in the governance of the service have the capacity, skills and
competencies necessary to effectively meet the requirements of their leadership
and managerial roles.
Regular safety walk-rounds by senior management, including meeting with staff,
listening to their insights on infection prevention and control, identifying examples
of good practice and areas for improvement, with documentation of the
conclusions and actions to be taken.
Clinical leaders ensure oversight and coordination of infection prevention and
control activities at the point of care.
Arrangements are in place for the timely sharing of information about healthcare-
associated infection incidents and outbreaks within the service.
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Local governance arrangements are in place to help share resources between
hospitals where appropriate.
Theme 6: Workforce
Standard 6.1.
Service providers plan, organise and manage their workforce to meet the
services’ infection prevention and control needs.
What a service meeting this standard looks like
Staffing, including infection prevention and control personnel, is maintained at levels that are recognised as appropriate by international evidence to safely meet the service’s infection prevention and control needs and activities, including appropriate staffing levels for out-of-hours arrangements.
Each hospital has a multidisciplinary infection prevention and control committee, a drugs and therapeutics committee and an antimicrobial stewardship subcommittee as deemed appropriate by the hospital, with established formal linkages with other relevant committees within the service.
Infection prevention and control and antimicrobial stewardship teams have core members and can request additional members when required. The infection prevention and control and antimicrobial stewardship workforce is organised and managed to work in multidisciplinary teams.
Patient care areas have appropriate numbers of staff to ensure infection prevention and control needs are met.
The workforce plan includes a training needs analysis for all grades of staff in order to deliver safe and effective infection prevention and control practices.
Service providers implement workforce contingency and succession planning for all staff, including trained specialist staff in infection prevention and control, to seamlessly continue to deliver a safe, effective, and sustainable service as staff leave or transfer to other parts of the service.
Regular review and evaluation of the management of the workforce, and the service’s response to changes in workload and the resources available, to ensure the consistent delivery of safe and effective infection prevention and control in the service, are undertaken.
Workload distribution is regularly reviewed with protected time being allocated to staff for surveillance, monitoring or quality improvement activities.
Arrangements are in place to support sharing of expertise and resources across the relevant staff disciplines within the service.
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Quality and safety
The focus of this section is about how hospitals ensure that infection prevention and
control outbreaks, including of COVID-19, are managed to protect people using the
healthcare service.
This includes how the services identify any work practice, equipment and
environmental risks and put in place protective measures to address the risk,
particularly during a pandemic.
It also focuses on how these services ensure that staff adhere to infection prevention
control best practice and antimicrobial stewardship to achieve best possible
outcomes for people during the ongoing COVID-19 pandemic.
For the purpose of this inspection, inspections will monitor compliance in relation to
the following themes and standards:
Theme 2: Effective Care and Support
Standard 2.6: Healthcare is provided in a clean and safe physical environment
that minimises the risk of transmitting a healthcare-associated infection.
What a service meeting this standard looks like
Design and Layout: A physical healthcare environment is planned, designed, developed and maintained to facilitate effective cleaning and compliance with infection prevention and control best practice. The size, complexity and specialities of the service are considered when planning the design and layout of the facility. Patient accommodation is planned and managed in a way that minimises the spread of healthcare-associated infections and maintains the patient’s dignity and privacy in line with national guidelines. Patient pathways allow for physical distancing in emergency departments, theatre and treatment rooms, inpatient bedrooms, examination room layouts, diagnostics and x-ray and all waiting areas. Physical environmental hygiene and safety: Arrangements and documented specifications are in place for cleaning and disinfection of the physical environment, in line with best practice guidance. This includes clearly defined responsibilities for staff involved in cleaning. Arrangements and specifications are in place for linen and laundry management
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including cleaning, decontamination, collection, transport and storage, in line with best practice. Arrangements and specifications are in place for the management of reusable cleaning textiles in line with best practice. Arrangements and specifications are in place for waste management including arrangements for safe handling, segregation, storage, transportation and disposal, in line with national waste management guidelines and legislation. Formalised arrangements are in place to monitor and inspect the physical infrastructure, maintenance and environmental cleanliness to ensure the service complies with national standards. A quality improvement plan is implemented if any areas for improvement are identified.
Theme 2: Effective Care and Support
Standard 2.7
Equipment is cleaned and maintained to minimise the risk of transmitting a
healthcare-associated infection.
What a service meeting this standard looks like
All equipment is safely and effectively cleaned, decontaminated, maintained and managed in accordance with legislation, the manufacturer’s instructions, national medical devices and equipment standards policy, standards and best practice guidance.
Arrangements and documented specifications are in place for cleaning, disinfecting and sterilising equipment. This includes clearly defined responsibilities for staff.
Equipment designated ‘single use’ is not re-used under any circumstances.
Dedicated equipment in rooms designated for isolation is appropriately decontaminated prior to use on another patient.
Reusable non-invasive equipment or medical devices is decontaminated, as appropriate for the level of infection risk, between each patient use.
There are designated storage areas for large items of equipment such as beds, mattresses, hoists, wheelchairs and trolleys which are clean but not in use.
Regular monitoring and inspection of the cleanliness of equipment is undertaken. Action is taken to address any areas identified for improvement.
Guide to HIQA’s targeted monitoring programme against the National Standards for the prevention and control of
healthcare-associated infections in acute healthcare services during the COVID-19 pandemic
Health Information and Quality Authority
Page 23 of 30
Theme 3: Safe Care and Support
Standard 3.1. Service providers integrate risk management practices into daily
work routine to improve the prevention and control of healthcare-associated
infections.
What a service meeting this standard looks like
Systems for the proactive identification, assessment, mitigation, monitoring and reporting of infection risks are in place and in line with the service’s risk management policy.
The service regularly reviews any significant infection risks to patients by conducting service-wide infection prevention and control risk assessments. This includes reviews during periods of service reorganisation or when demand and resources change such as overcrowding, infection outbreaks and understaffing. Arrangements are in place to minimise the impact on infection prevention and control activities.
Any risks that cannot be adequately mitigated at the point of care are escalated to the next level of management for action, and to the national service provider if necessary.
Staff are trained and assisted to integrate risk management techniques into their daily tasks and duties that involve infection prevention and control. This includes assessing patients for risk of infection, assessing the environment for risk of infection and implementing standard precautions and transmission-based precautions, in line with best practice.
Staff adhere to the service’s infection prevention and control policies and procedures, guidelines and standards in order to effectively anticipate and mitigate healthcare-associated infections and antimicrobial resistance risks.
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Theme 3: Safe Care and Support
Standard 3.8. Services have a system in place to manage and control infection
outbreaks in a timely and effective manner.
What a service meeting this standard looks like
Arrangements are in place to assist staff in promptly recognising and responding to any symptoms or signs in patients which are suggestive of an outbreak. The infection prevention and control team is informed of any confirmed, probable or suspected cases.
A surveillance system that can detect and respond to any emerging critical data that meet the case definition criteria for an outbreak is in place.
Up-to-date outbreak management policies and procedures are available that outline staffing arrangements, leadership roles and responsibilities, communication strategy, outbreak control measures and surveillance activities during any outbreaks.
Any suspected or confirmed outbreaks are promptly notified to the medical officer of health in the Departments of Public Health, in line with legislation.
Everyone who needs to know about the status of an outbreak within and between healthcare services is informed and updated. Staff are supported during an outbreak.
A mechanism is in place for an out-of-hours response to an outbreak that outlines staffing, reporting and patient placement arrangements.
A multidisciplinary outbreak control team is convened in the event of a suspected or confirmed outbreak in line with best practice that is chaired by a designated member of the senior management team.
An outbreak management plan is implemented that outlines the steps for managing, containing and monitoring the outbreak. An escalation plan is put into place if the situation deteriorates.
The outbreak is immediately investigated by the infection prevention and control team, supported by senior management, risk management and patient safety and quality specialists, which includes identifying the responsible micro-organism, the route of transmission and groups of patients at risk.
A report outlining the outcome of the investigation of the outbreak is presented to senior management within and between all healthcare services, with feedback of outbreak control learning points provided to staff to identify any areas for improvement.
Guide to HIQA’s targeted monitoring programme against the National Standards for the prevention and control of
healthcare-associated infections in acute healthcare services during the COVID-19 pandemic
Health Information and Quality Authority
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Bibliography
Health Act 2007. Dublin: The Stationery Office; 2007. Available online from:
http://www.irishstatutebook.ie/eli/2007/act/23/enacted/en/print
Health Information and Quality Authority. National Standards for infection prevention
and control of healthcare-associated infections in acute healthcare services. Dublin:
Health Information and Quality Authority; 2017. [Online]. Available online from:
https://www.hiqa.ie/reports-and-publications/standard/2017-national-standards-
prevention-and-control-healthcare
Health Information and Quality Authority. Enhanced Authority Monitoring Approach
Guidance. Dublin: Health Information and Quality Authority; 2017. [Online]. Available
online from: https://www.hiqa.ie/sites/default/files/2018-02/Enhanced-Authority-
Monitoring-Approach_Guidance.pdf
Health Service Executive Health Protection Surveillance Centre. Acute Hospital
Infection Prevention and Control Precautions for Possible or Confirmed COVID-19 in
a Pandemic Setting. Dublin: Health Service Executive Health Protection Surveillance
Centre., 2020 Available online from:https://www.hpsc.ie/a-
z/respiratory/coronavirus/novelcoronavirus/guidance/infectionpreventionandcontrolgu
idance/Infection%20Prevention%20and%20Control%20Precautions%20for%20Acut
e%20Settings%20-COVID-19.pdf
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Appendix 1 Sample documentation and data request for review
on the day of inspection
Data request – for review on day of inspection
1 Total number of hospital beds
2 Total number of in-patients today
3 Total number of single rooms in the hospital
How many of these rooms have an ensuite toilet facilities?
4 Number of inpatients for which single room isolation is indicated today
5 Number of inpatients isolated in single rooms today
6 Location of in-patients where single room isolation is indicated and who are not isolated in single rooms
7 Number of suspected or confirmed cases of COVID-19 inpatients/outbreak line listing if relevant
8 Number of suspected or confirmed cases of COVID-19 staff/outbreak line listing if relevant
9 Number of staff that have tested positive for COVID-19
to date
10 Are all confirmed cases of COVID-19 inpatients in single rooms or cohorted appropriately
11 Number of COVID-19 cohorted isolation areas in place
12 Any other outbreak of infection in hospital today
13 Number of neutral or negative pressure isolation rooms
Guide to HIQA’s targeted monitoring programme against the National Standards for the prevention and control of
healthcare-associated infections in acute healthcare services during the COVID-19 pandemic
Health Information and Quality Authority
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On-site documentation and data request
Infection prevention & control documentation and data request
Infection Prevention and Control team organogram (and email to HIQA)
1. Infection Prevention and Control risk register
2. List of Infection prevention and control-related risks only on the hospital risk register risks and existing controls on the current hospital risk register (these will be reviewed and discussed during management meetings)
Policy or procedure or Guideline Yes/ No Date
written
Review
date
Ratified by
Outbreak management
policy/guidelines
COVID 19 preparedness/ contingency
plans
Hospital policy on standard and
transmission based precautions or
equivalent
Admission and discharge policy during
an outbreak (inclusive of streaming of
patients on admission for
scheduled/unscheduled care)
Interfacility transfer form
IPC patient placement policy
Occupational health guidance/policy in
relation to IPC – COVID-19
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Sample Documentation Email Request
The following documents are to be emailed to HIQA through the office of the
CEO/General Manager to the email address: [email protected]. Documents
emailed to HIQA by email must not contain named patient information.
Email Request
1 COMMITTEES – Terms of reference (TOR)
Infection Prevention and Control Committee: TOR and list of members by discipline
Outbreak Control team membership/TOR
2 MEETING MINUTES
Minutes/agenda of Safety and Quality Executive Steering Group for last 3 meetings
Minutes of infection prevention and control committee meetings for the last 3 meetings and any reports
circulated at these meetings.
Minutes/agenda of COVID-19 Outbreak Control team (check frequency of meetings)
Minutes of Hospital Group IPC meetings 2020
3 REPORTS
Infection prevention and control annual report (latest report) and programme plan
Microbiology surveillance report for the last quarter
Antimicrobial stewardship annual report (latest report)
Hospital hygiene audit report (last 12 months)- 1 page trended report.
Patient equipment hygiene audit report results (last 12 months)1 page trended report.
IPC incidents – tracked and trended report (last 12 months if available)
Written reports of any outbreaks or clusters of infection in the hospital in the last 12 months
4 Plans (Quality Improvement Plans)
QIP developed following previous HIQA PCHCAI inspection – updated version
5 Data
% of staff trained in hand hygiene in the last two years – presented by staff discipline
Infection Prevention and Control: Trending and overall % completed staff training records in relation to
outbreak management, TBP/SBP (clinical and non-clinical staff, agency, bank staff)
PLEASE DO NOT RETURN LISTS OF NAMES WHO HAVE COMPLETED TRAINING.
Guide to HIQA’s targeted monitoring programme against the National Standards for the prevention and control of healthcare-associated infections in acute healthcare services
during the COVID-19 pandemic
Health Information and Quality Authority
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Appendix 2 HIQA’s Risk Escalation process
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Published by the Health Information and Quality Authority
(HIQA).
For further information please contact:
Health Information and Quality Authority
George’s Court
George’s Lane
Smithfield
Dublin 7
D07 E98Y
+353 (0)1 814 7400
www.hiqa.ie
© Health Information and Quality Authority 2020