national infection prevention and control guideline

Administrative Components

National Infection

Prevention and

Control Guideline

General Directorate of Infection Prevention and Control

First Edition 2016

National Infection Prevention and Control Manual

Chapter 1

Infection Control Program

Guideline No:

NIPCM – I – 01

Subtitle:

ADMINISTRATIVE COMPONENTS OF THE IPC PROGRAM

Issuing Authority: General Directorate of

Infection Prevention and Control (GDIPC)

Applies To:

All MOH Healthcare Facilities

Effective Date:

April 2016

Page 1 of 5 General Directorate of Infection Prevention and Control

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 – Infection Prevention and 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:

Infection Control Programs are active on three levels:

4.1 General Directorate of Infection Prevention and Control (GDIPC) - The regulatory body of

Infection Prevention and 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


Chapter 1


Guideline No:

NIPCM – I – 01

Subtitle:




Applies To:


Effective Date:

April 2016


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:


Chapter 1


Guideline No:

NIPCM – I – 01

Subtitle:




Applies To:


Effective Date:

April 2016


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.


Chapter 1


Guideline No:

NIPCM – I – 01

Subtitle:




Applies To:


Effective Date:

April 2016


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 General Directorate of Infection Prevention and Control

(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.


Chapter 1


Guideline No:

NIPCM – I – 01

Subtitle:




Applies To:


Effective Date:

April 2016


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: SIGNATURE

DR. ZEINAB ABBAS SOLTAN, MD Acting Director, Planning and Development General Directorate of Infection Prevention and Control

DR. HAIL M. ALABDELY, MD General Director General Directorate of Infection Prevention and Control

national infection prevention and control guideline

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