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Infection Prevention and Control Commissioning ToolkitGuidance and information for nursing and commissioning staff in England
Supported by
A joint RCN and IPS publication
This publication is being reviewed in 2019
This publication is due for review in January 2018. To provide feedback on its contents or on your experience of using the publication, please email [email protected]
RCN Legal Disclaimer
This publication contains information, advice and guidance to help members of the RCN. It is intended for use within the UK but readers are advised that practices may vary in each country and outside the UK.
The information in this booklet has been compiled from professional sources, but its accuracy is not guaranteed. Whilst every effort has been made to ensure the RCN provides accurate and expert information and guidance, it is impossible to predict all the circumstances in which it may be used. Accordingly, the RCN shall not be liable to any person or entity with respect to any loss or damage caused or alleged to be caused directly or indirectly by what is contained in or left out of this website information and guidance.
Published by the Royal College of Nursing, 20 Cavendish Square, London W1G 0RN
© 2016 Royal College of Nursing. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise, without prior permission of the Publishers. This publication may not be lent, resold, hired out or otherwise disposed of by ways of trade in any form of binding or cover other than that in which it is published, without the prior consent of the Publishers.
Third Edition
Acknowledgements
The Royal College of Nursing (RCN) and Infection Prevention Society (IPS) would like to thank the following for leading the revision of the publication:
Rose Gallagher, RCN Professional Lead for Infection Prevention and Control
Sarah Turner, Senior Health Protection Nurse, Stockport Metropolitan Borough Council and IPS representative
Chris Sweeney, Associate Head of Health Protection, Wigan Council and IPS representative
Stuart Abrahams, RCN Policy Adviser
We are very grateful for the support and advice of NHS England and members of the RCN/IPS Commissioning workgroup who contributed to the development of this resource.
This is a joint publication by the RCN and IPS. The RCN supports the vision of the IPS that no person is harmed by a preventable infection.
The IPS and RCN’s Infection prevention and control commissioning toolkit was originally developed at a time when the NHS in England was undergoing considerable reform and transition to a new commissioning structure. The toolkit has been revised twice since being first published in 2012. Further revision of the toolkit reflects a more focused approach to developments in infection prevention and control within health and social care and provides direction for future priorities that impact on health, public health and antimicrobial resistance.
This resource assumes all providers of health and social care are fully compliant with the criteria and elements of the Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance (DH, 2015) and The CQC Fundamental Standards (http://www.cqc.org.uk/content/fundamental-standards) introduced in April 2015.
For further information on the IPS and RCN infection prevention and control activity please visit www.ips.uk.net and www.rcn.org.uk/ipc
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Royal College of NuRsiNg aNd iNfeCtioN PReveNtioN soCiety
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Foreword 4
1. Introduction 5
Developing a strategic focus for prevention of infection 5
Why focus on these issues? 5
Building an evidence base 6
2. How to use this toolkit 8
Who will find the toolkit useful ? 8
3. Reducing the incidence of HCAI: moving towards a zero-tolerance approach 9
Expectations and the role of commissioning organisations 9
Expectations of provider organisations 10
4. Indicators 11
Using the IPC commissioning indicators 11
Mandatory indicators 11
Basket of suggested indicators 11
Quality requirements: threshold method of measurement and consequences of breach 13
Contents
Infection Prevention and Control Commissioning Toolkit
Guidance and information for nursing and commissioning staff in England
5. Appendices: 14
1: Infection prevention and control basket of suggested indicators – secondary care 15
2: Infection prevention and control basket of suggested indicators – primary and community care 27
3: Infection prevention and control basket of suggested indicators – mental health 37
4: Infection prevention and control basket of suggested indicators – social care 48
5: Leading and developing the health care associated infection (HCAI) system 56
7. References and further reading 59
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In recent years vital work has been undertaken across the
health care system to tackle issues associated with infection prevention and control (IPC). The reduction in the number of some health care acquired infections (HCAIs), particularly C. difficile infection which has fallen by 42% since the beginning of the decade, is evidence of the improvements made.
The prevention of infection is fundamental to the safety and quality of care delivered to patients and remains a key priority for the NHS. As the epidemiology of many HCAI cases becomes more complex and as the threat of antimicrobial resistance increases, it is essential that we build on the progress made to date and work to identify new ways to improve practice.
To help achieve this we will need to develop the assurance processes currently in place; focusing our efforts not only on the measurement of targets and objectives, but also on the identification of learning and the implementation of action to drive improved outcomes for patients.
Fundamental to this approach will be the collaboration between different health care organisations to achieve a shared understanding of pertinent issues and ambition to enable improvement across the whole health economy. The commitment and support from leaders across the healthcare system will be vital for supporting this and for ensuring we can continue to drive improvement around infection prevention and control.
NHS England is pleased to support this resource which will help organisations to develop ways of working that meet the current and future challenges associated with this area of national priority.
Commissioners are encouraged to use this tool in the development of purposeful IPC strategies that are shaped, owned and delivered by local health economies.
Foreword
Putting quality at the centre of everything we do
A statement from Dr Mike Durkin, Director of Patient Safety, NHS England
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Developing a strategic focus for prevention of infection
The prevention of infection is a key priority for the NHS, as set out in Five Year Forward View (NHS England, 2014) and is central to reducing the need and demand for antibiotics, the main driver for antimicrobial resistance (AMR). Greater investment in the prevention of infection from a public health and infection prevention and control perspective offers one solution to the challenges faced by the NHS and offers part of a solution to enable best use of NHS budget, through improved productivity and efficiency.
Reducing health care associated infections (HCAIs) remains high on the government’s safety agenda and in the general public’s expectations for quality of care. Since 2008, there has been a legal requirement on the NHS and on all health and social care organisations to implement the Health and Social Care Act 2008, and to meet the standards of the Code of Practice within the Act (DH, 2015). The prevention and management of HCAIs has also evolved to become an integral element of new NHS structures developed since the toolkit was first introduced. The recent NHS England ‘Sign up to safety’ campaign and development of national patient safety expert groups/collaboratives and quality improvement initiatives is a positive step forward and an opportunity to support ongoing improvements and learning in infection prevention and control (IPC).
The previous commissioning toolkits were developed to support both commissioning and provider organisations. They focused on helping to ensure that structures, objective setting, processes, monitoring and assurance arrangements and resources for the prevention of HCAIs are in place and regularly reviewed. The RCN and IPS recognise that moving forward, more needs to be done to provide a strategic focus for improvements in the recognition, management and reduction in HCAIs in order to manage the risks associated with antimicrobial
resistance and protect the health and wellbeing of the public, as well as to reduce health care costs. The RCN and IPS believe that the following improvements can be made.
• Commissionersaligningeffortsacrosspublichealth, primary and secondary health care, and social care on key infections that would benefit from a ‘joined up’ approach to prevention, recognition and management.
• Consideringastrategicfocusonthreekeychallenges for inclusion in all future outcomes frameworks which would benefit from collaboration. These are the prevention, recognition and management of:
- pneumonia, including community-acquired pneumonia (CAP) and pneumonia that is acquired as a result of health care
- urinary tract infections (UTIs)
- sepsis.
• Strengtheningtheroleofprimarycareandcommunity services such as general practice, community nursing, heath visiting, community mental health teams and care homes to have a greater role in embedding and supporting public health strategies. This will help reduce the burden of preventable long-term conditions and support population health to reduce the need for health care interventions.
Why focus on these issues?
Pneumonia and UTIs are two of the leading causes of sepsis (Parliamentary and Health Service Ombudsman, 2014). Pneumonia and UTIs can be health care associated and are estimated to be responsible for 19.7% and 13.9% of health care associated infections respectively (HPA, 2012). They are also common in community settings, often developing independently of
Introduction
1
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Figure 1
Pneumonia, UTIs and sepsis are associated with a number of preventative and improvement strategies associated with health and wider public health. This close interaction offers a unique opportunity to impact on current priorities such as antimicrobial resistance, nutrition and hydration, surveillance of infection, the reduction of health care costs and supporting self-care. Figure 1 illustrates this relationship.
Building an evidence base
The RCN and IPS acknowledge the current lack of evidence supporting the use of the commissioning process to improve patient outcomes through the prevention of infection. Both organisations are committed to contributing to the development of evidence in this area where possible and this toolkit is one example of how this activity has started. The process undertaken for revision of this version of the toolkit is described and includes a review of available evidence and a description of the toolkit development methodology.
Revision methodology
The first edition of the commissioning toolkit was published in 2012 in the absence of any existing guidance on the specific inclusion of IPC for commissioning purposes beyond the requirement to meet national indicators or targets. Developed through expert consensus advice and analysis of available evidence, the toolkit provided a selection of indicators
any contact with health care and are a leading cause of morbidity and mortality.
It is estimated that between 0.5% and 1% of adults will develop CAP every year in the UK. Pneumonia can be a serious illness and 1.2% to 10% of adults admitted to hospital with CAP require care in intensive care units. In these circumstances the estimated risk of dying is more than 30%, with pneumonia-related deaths more common in people aged 84 years and over (NICE, 2014).
The incidence of urinary tract infection increases with age and are the second most common clinical indication for empirical treatment with antibiotics in primary and secondary care (SIGN, 2012). Complications include pyelonephritis, exacerbation of underlying conditions such as diabetes and prostatitis in men. Successful treatment of UTIs is increasingly challenged by the presence of resistant bacteria (for example, extended-spectrum beta-lactamases [ESBL] producing organisms including E. coli, which require treatment with the use of discrete antibiotics which may be toxic, limited in their ability to treat infections successfully, and expensive.
Sepsis occurs as a result of infection and is a leading cause of death in the UK, causing between 36,000 and 64,000 deaths per year. For patients admitted with severe sepsis, there is an overall mortality rate of approximately 35% (Daniels, 2011). The importance of sepsis has been heightened following the publication of the Parliamentary and Health Service Ombudsman report (2014) and announcement on the introduction of a CQUIN to support recognition and management of sepsis.
UTI
CAP
SepsisThis publication is being reviewed in 2019
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to support commissioners and providers of NHS care following the introduction of the Health and Social Care Act in 2012, which introduced a focus on clinically, as opposed to centralised commissioning.
This toolkit has been developed to support the principle that health and social care services must be commissioned to achieve high-quality care by delivering safe, effective and efficient services that reflect essential standards for quality and safety. The toolkit takes into account the importance of:
• publicandpopulationhealth
• increasingantimicrobialresistance
• theintroductionofstrategiestoreduceother‘harms’ and the increasing focus on patient safety
• agreateremphasisonoutcomesasameasureofquality.
Further revision of the toolkit provided an opportunity to learn from user feedback and reflect on the experience of clinically-based commissioning over the past two years. Reflection highlighted the need to ensure that IPC priorities remain current and are reflected in provider commissioning contracts, and that assurance processes are robust. This reflection also identified the need to strive to develop outcomes, as opposed to process or structural indicators.
The process for revision was:
• asearchforevidencedemonstratingthevalueoflocal commissioning generally and a systematic search for the impact of IPC as part of commissioning quality requirements
• developmentofindicatortablesthroughexpertknowledge (working group and consultation with professional IPC networks), signposting of applicable evidence and identification of gaps.
A search of the literature identified no prior publications or evidence to inform an established methodology for commissioning of IPC.
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• healthandsocialcareproviderorganisationsinboth acute and community settings
• providerorganisationsthatsub-contractservices
• generalpractitioners
• independentproviderorganisations(forexample,dental and optometry services)
• organisationsconsideringtenderingforNHSprovider services
• localauthoritiesandassociatedhealthandwellbeing boards
• IPCspecialistpractitionersanddirectorsofIPC.
This revised toolkit provides information to support professionals involved in the commissioning or assurance of health and social care services. It seeks to highlight organisational approaches to infection prevention and control across primary, secondary and social care settings.
It provides a series of optional indicators to support performance management and assurance against provider contracts. Where the indicators are used they should recognise and reflect local priorities. Commissioners may additionally wish to develop cross-organisational strategies to ensure consistency across local health economies.
This toolkit also provides an example HCAI reduction plan for commissioners to adapt for local use (see Appendix 5). A HCAI reduction plan is a contractual requirement for all commissioned provider contracts.
Who will find the toolkit useful?
The toolkit will be of particular value to commissioning organisations such as clinical commissioning groups (CCGs) and commissioning support units (CSUs).
It should be used together with expert infection prevention advice to identify priorities and ensure monitoring strategies are used appropriately and proportionally.
The toolkit may be a useful resource for:
• CCGs,commissioningleadswithresponsibilityforIPC, antimicrobial resistance and antimicrobial prescribing
• performancemonitoringteams
• safetyandqualityteams
• NHSEnglandanditsassociatedsub-groups
2How to use this toolkit
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• Delivering for patients. The 2015/16 Accountability Framework for NHS trust boards (TDA 2015).
• Everyone counts: planning for patients 2014/15 to 2018/19 (NHSE, 2013).
• Commissioning for quality and innovation (CQUIN) 2015/16 guidance (NHSE, 2015).
• Adult Social Care Outcomes Framework 2015/16 (DH 2014).
• Public Health Outcomes Framework 2013-2016 (DH 2012 updated 2015).
• NationalInstituteforHealthandClinicalExcellence(NICE) guidelines or quality statements.
• Healthbuildingnotes,technicalmemorandaandthe Choice framework for local policy and procedures (CFPP) form a suite of evidence-based policy and guidance documents on the management and decontamination of reusable medical devices (DH, 2013).
• AchievingHCAIreductioninlinewithnationalandlocal objectives.
• Meetingtherequirementsofthe‘compositeindicator’ (when available in 2016).
• ReportingHCAIdeathsonanypartofthedeathcertificate according to local policy and procedures.
• Ensuringthatlessonslearnedfromanyincidentsorregulatory recommendations are completed in a timely way.
All commissioning organisations require assurance about the systems and processes that are in place. This should include evidence which can be used to provide a benchmark or demonstrate improvement in services provided and may include:
Expectations and the role of commissioning organisations
Commissioners and providers must not accept that HCAIs are an inevitable or acceptable risk in health or social care. Commissioning organisations will hold providers to account for their performance, and assess their contribution to sustained improvement in infection prevention and control practices that reduce HCAIs and antimicrobial resistance.
To achieve this they will evaluate local objectives systematically across the organisations they commission services from. They will ensure that there is proportionality to expectations associated with different care settings. Commissioning teams will review available surveillance data so that they can monitor progress against nationally set objectives for specific organisms, other agreed indicators and learning identified from post-infection reviews (PIR) or root cause analysis of incidents.
Commissioning organisations should be assured that all services commissioned or contracted by them, or on their behalf, are compliant with a range of guidance, policy and regulations, as detailed below.
• The NHS Mandate (DH, 2014).
• The NHS Outcomes Framework 2015-2016 (DH, 2015).
• The UK 5 year antimicrobial resistance strategy 2013-2018 (DH, 2013).
• The scope of registration (CQC, 2015).
• Guidance for providers on meeting the regulations (CQC, 2015)
• Risk assessment framework (Monitor, 2015).
Reducing the incidence of HCAI: moving towards a zero-tolerance approach
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• toactivelyengagewiththeprocessesforHCAI/IPCperformance and quality monitoring
• tobeactivemembersofanyrelevanthealtheconomy infection prevention group or other appropriate forums.
• evidenceofservicereview
• receiptofappropriateandadequateinformation
• evidenceofmonitoringinformation
• evidenceofactionbeingundertakenwhenconcernsare raised
• evidenceoffailuretomeetexpectedstandardordiscrepancies in data which been noted by the commissioner
• triangulationofdata–evidenceofimprovedoutcomes in relation to quality parameters of safety, effectiveness and patient experience.
Expectations of provider organisations
There is a legal requirement on all provider organisations to meet the standards described in the Code of practice on the prevention and control of infections and related guidance (DH, 2015). This is integral to CQC registration and ongoing compliance.
This toolkit emphasises further best practice requirements expected of provider organisations, which include:
• tohaveanassuranceframeworkthatreflectsthelocal commissioning organisation’s HCAI reduction plan and contractual requirements
• toundertakeassessmentsoftheircompliancewiththe Code of Practice (DH, 2015) at intervals agreed with the commissioning organisation
• tosubmitcompliancereportstotheboardforinternal assurance and the commissioning organisation for external assurance
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should focus on the improvements needed, based on local requirements. Some commissioning and provider organisations may be more highly developed in measuring and reporting indicators than others. However, there should be a common aim to standardise these where possible, whilst developing additional opportunities for quality improvement at a local level. Ideally this should be a shared process between commissioners and providers based on local need and the aim of improving patient safety.
Mandatory indicators
At the time of publication there are only two mandatory objectives included in the national contract including the continued zero tolerance of MRSA blood stream infection and an ongoing focus on reducing C. difficile infections. Additional optional indicators supporting the achievement of these mandatory objectives are provided to support an integrated approach to prevention and management of these infections.
Indicators help organisations understand, compare, predict outcomes and improve care. They should align contractual requirements to compliance with NHS England’s Everyone counts, planning for patients 2014/15 to 2018/19 (2013) and Monitor’s Risk assessment framework (Monitor, 2015). They should be used to support the delivery of the Public health outcomes framework (DH, 2015). Indicators should also reflect requirements to implement national, regional and local best practice guidance. This will ensure that the priorities for infection prevention and control are in provider contracts.
Basket of suggested indicators
In addition to the mandatory indicators a further basket of optional general indicators is provided to meet the needs of different care settings (see appendices) developed by the RCN and the IPS.
An indicator (in the context of improving quality of care) is described as a summary measure that aims to describe in a few numbers as much detail as possible about a system, to help understand, compare, predict, improve, and innovate (RCN, 2009).
Health indicators include process and outcome indicators. Historically the focus has been on process indicators to reflect standards of care that patients receive. The RCN and IPS acknowledge the iterative development of outcome indicators to support improvements in IPC beyond MRSA bloodstream and C. difficile infections.
Using the IPC commissioning indicators
The IPS and the RCN have developed this toolkit for commissioning and provider health and social care organisations to support the commissioning of infection prevention and control and optimal use of antimicrobial agents. Our aim is that the toolkit is an enabling resource designed to support commissioner and provider organisations to communicate and agree the content and ambition of their contract. It is not an alternative to the Code of practice on the prevention and control of infections and related guidance (DH, 2015) but will support organisations to ensure that the quality and safety of care provided is continually improved.
The toolkit includes mandatory indicators, and a basket of indicators to consider for inclusion in local commissioning contracts (see Appendix 1). There is also an example of a local HCAI reduction plan that can be adapted by commissioners for local use (see Appendix 2).
Health and social care commissioners require provider organisations to guarantee clean environments and safe practices to prevent HCAIs. The assurance process should not mirror other compliance or regulations. It
Indicators
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collated, detailed information. Commissioners can also decide that specific assurance for some of the suggested indicators is not required because they are confident that practice is well-embedded. In effect, each provider should have its own unique set of indicators and information schedule requirements to facilitate the robust assurance of performance required on IPC for the specific provider. The IPS has developed quality improvement tools for infection prevention, which are available from the IPS website. They provide evidence-based tools for infection prevention, designed to measure baseline compliance with standards and identify areas for improvement.
Table 1 provides a summary overview of how the indicator overarching heading can be applied to different care settings.
The indicators for each setting have been grouped into several headings. Table 1 provides an overview of the indicators which have been applied to the different care settings.
By suggesting a focus on three key challenges (pneumonia, urinary tract infections and sepsis) relevant to all outcome frameworks this resource provides an opportunity for consideration and further exploration of joint IPC and public health activity, moving forward. Any future national indicators need to be developed over time with the support of leading national organisations and therefore these are included as ‘ambition indicators’ only, which describe generic requirements to help raise awareness and encourage organisations to consider their contribution to these issues. Indicators are presented in the format of the NHS national contract so that users can lift the detail and place it into individual provider contracts. This can also be adapted for inclusion in adult social care contracts.
Commissioners may choose the indicators based on local need and this may be informed by local surveillance data, information from provider compliance reports and other local intelligence. These can be included either as indicators or in the information schedule of the contract as regularly
Table 1
Secondary care Primary care Mental health Social care *
Ambition indicators x x x x
Organisational elements x x x x
Service user involvement x x x
MRSA, CDI and other significant HCAIs
x x x x
IPC practice x x x x
Prescribing x x x N/A*
medicines management
Monitoring x x N/A x
Vaccinations x x x x
Physical health N/A N/A x N/A
*Social care indicator basket has combined indicators proportionate to social care settings and not defined headings as per NHS provider services.
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Quality requirement: threshold method of measurement and consequences of breach
Quantifiable measurements are used to reflect the critical success of an organisation, service or provider. As indicators reflect goals, each indicator has a target or plan. The quality requirement serves as a benchmark for comparison or guidance against which a breach may be applied.
Note about thresholds
The indicator baskets (Appendices 1-4) suggest thresholds that can be agreed through local negotiation between commissioner and provider to decide what is appropriate and proportionate.
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The suggested table of indicators are relevant to all health and adult social care settings based on expectations agreed by RCN/IPS members working in commissioning roles. It is anticipated that any indicators selected will be agreed following discussions between commissioner and provider organisations based on the service provided and patient population needs. Suggested indicators are exclusive of the requirements of the Health and Social Care Act (2008), Code of Practice on the prevention and control of infections and related guidance (DH, 2015).
The table reflects the NHS national contract and local quality requirements and is also mapped against the UK five-year antimicrobial resistance strategy (DH, 2013). The consequence of any breaches of quality requirements should be subject to the appropriate clause within local contracts.
Appendices: Infection prevention and control basket of suggested indicatorsThis publication is being reviewed in 2019
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App
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ww
.nic
e.or
g.u
k/gu
idan
ce/q
s61
NIC
E C
G 1
39 (
2012
) In
fect
ion:
Pre
vent
ion
and
cont
rol
of h
ealt
hcar
e-as
soci
ated
infe
ctio
ns in
pri
mar
y an
d co
mm
unit
y ca
re
ww
w.n
ice.
org.
uk/
guid
ance
/cg1
39
Parl
iam
enta
ry a
nd
Hea
lth
Ser
vice
s O
mbu
dsm
an
(201
4) T
ime
to A
ct, s
ever
e se
psis
: rap
id d
iagn
osis
and
tr
eatm
ent s
aves
live
s w
ww
.om
buds
man
.org
.uk/
__d
ata/
asse
ts/p
df_fi
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2266
6/FI
NA
L_S
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s_R
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NIC
E (
2015
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ualit
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anda
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rina
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ract
infe
ctio
ns
in a
dult
s Q
S90
ww
w.n
ice.
org.
uk/
guid
ance
/qs9
0
NIC
E (
2013
) Q
ualit
y St
anda
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rina
ry t
ract
infe
ctio
n in
infa
nts,
chi
ldre
n an
d yo
ung
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nder
16
QS3
6 w
ww
.nic
e.or
g.u
k/gu
idan
ce/q
s36
NIC
E C
G 1
61 (
2013
) Fa
lls: a
sses
smen
t and
pre
vent
ion
of
falls
in o
lder
peo
ple
w
ww
.nic
e.or
g.u
k/gu
idan
ce/c
g161
This publication is being reviewed in 2019
16
InfectIon PreventIon and control commIssIonIng toolkIt
Return to contents
Qua
lity
requ
irem
ent
Thre
shol
d (r
epor
ting
ex
pect
atio
n)
Met
hod
of
mea
sure
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mm
ents
CMO
st
rate
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on
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Evid
ence
/gui
danc
e
Th
e pr
ovid
er h
as in
pl
ace
a st
rate
gy t
hat
de
scri
bes
acti
ons
to
reco
gnis
e, m
easu
re a
nd
man
age
susp
ecte
d ca
ses
of s
epsi
s
Evid
ence
of
stra
tegy
, in
clu
din
g h
ow it
will
be
rev
iew
ed a
nd
eval
uat
ed
Evid
ence
of
stra
tegy
an
d im
plem
enta
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pl
an
Stra
tegy
sh
ould
incl
ude
th
e ro
le o
f m
ult
i-di
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akeh
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and
com
mu
nic
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path
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trat
egy
may
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dev
elop
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nd
impl
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ted
in
colla
bora
tion
wit
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pr
ovid
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rgan
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1, 2
NH
S E
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and
(201
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nova
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QU
IN)
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15/1
6
ww
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nh
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nte
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upl
oads
/201
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/9-
cqu
in-g
uid
-201
5-16
Parl
iam
enta
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Hea
lth
Ser
vice
s O
mbu
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ime
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ct, s
ever
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psis
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tr
eatm
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aves
live
s
ww
w.o
mbu
dsm
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rg.u
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data
/ass
ets/
pdf_
file
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4/22
666/
FIN
AL
_Sep
sis_
Rep
ort_
web
.pd
f
Org
anis
atio
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lem
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IPC
is in
clu
ded
as a
re
gula
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enda
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rele
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orga
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scu
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PC
di
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1B
est
prac
tice
NIC
E (
2014
) Q
ualit
y St
anda
rd I
nfec
tion
pre
vent
ion
and
Con
trol
QS6
1 w
ww
.nic
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g.u
k/gu
idan
ce/q
s61
Th
e or
gan
isat
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velo
ps a
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own
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CA
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duct
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uar
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plia
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Th
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ode
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PC
pla
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nh
s-st
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16-1
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An
tim
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AM
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enda
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elev
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org
anis
atio
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mee
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MS
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mee
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rovi
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MS
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2B
est
Pra
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NIC
E G
uid
elin
e N
G15
(20
15)
Ant
imic
robi
al
stew
ards
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sys
tem
s an
d pr
oces
ses
for
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ctiv
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tim
icro
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ww
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idan
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ted
NIC
E (
2014
) Q
ualit
y St
anda
rd I
nfec
tion
pre
vent
ion
and
Con
trol
QS6
1
ww
w.n
ice.
org.
uk/
guid
ance
/qs6
1 P
rovi
der
take
s in
to
acco
un
t ad
vice
from
sp
ecia
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IP
C a
nd
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S pr
ovid
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eam
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um
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tails
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sion
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med
ial a
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n
Wh
ere
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ialis
t IP
C/
AM
S ad
vice
is n
ot
follo
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, th
e ra
tion
ale
and
deci
sion
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docu
men
ted
and
disc
uss
ed a
t th
e re
leva
nt
mee
tin
g (s
ee t
wo
indi
cato
rs a
bove
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1B
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ctic
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NIC
E G
uid
elin
e N
G15
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15)
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oces
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tim
icro
bial
med
icin
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e w
ww
.nic
e.or
g.u
k/gu
idan
ce/N
G15
/ch
apte
r/2-
Impl
emen
tati
on-g
etti
ng-
star
ted
This publication is being reviewed in 2019
Royal College of NuRsiNg aNd iNfeCtioN PReveNtioN soCiety
17 Return to contents
Qua
lity
requ
irem
ent
Thre
shol
d (r
epor
ting
ex
pect
atio
n)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/gui
danc
e
Th
e or
gan
isat
ion
em
ploy
s or
has
su
ffici
ent
acce
ss t
o a
suit
ably
re
sou
rced
an
d qu
alifi
ed
Infe
ctio
n P
reve
nti
on a
nd
Con
trol
Tea
m (
IPC
T),
A
nti
mic
robi
al
Stew
ards
hip
(A
MS)
te
am o
r sp
ecia
list
prac
titi
oner
to
mee
t th
eir
nee
ds
Spec
ialis
t ad
vise
rs
clea
rly
iden
tifi
able
Rec
ord
of
serv
ice
or
con
trac
t fo
r pr
ovis
ion
of
IPC
an
d A
MS
advi
ce
Con
trac
t m
ay b
e fo
r em
ploy
men
t or
adv
ice
and
shou
ld d
etai
l th
e n
um
ber
of h
ours
em
ploy
ed/c
ontr
acte
d,
role
des
crip
tion
, lin
es o
f co
mm
un
icat
ion
an
d go
vern
ance
str
uct
ure
s fo
r IP
C a
nd
wit
hin
pro
vide
r or
gan
isat
ion
1B
est
prac
tice
NIC
E (
2014
) Q
ualit
y St
anda
rd Q
S61
ww
w.n
ice.
org.
uk/
guid
ance
/QS6
1/ch
apte
r/L
ist-
of-
qual
ity-
stat
emen
ts
NIC
E G
uid
elin
e N
G15
(20
15)
Ant
imic
robi
al
stew
ards
hip:
sys
tem
s an
d pr
oces
ses
for
effe
ctiv
e an
tim
icro
bial
med
icin
e us
e w
ww
.nic
e.or
g.u
k/gu
idan
ce/N
G15
/ch
apte
r/2-
Impl
emen
tati
on-g
etti
ng-
star
ted
Pro
vide
r co
ntr
ibu
tes
to
wh
ole
econ
omy
stra
tegi
c pl
ann
ing
disc
uss
ion
an
d de
cisi
on m
akin
g on
H
CA
I re
duct
ion
Rec
ord
of a
tten
dan
ce
and
con
trib
uti
onM
inu
tes
of m
eeti
ngs
Loca
l HC
AI
prov
ider
or
prof
essi
onal
net
wor
ks
can
be
use
d as
a m
eth
od
of d
emon
stra
tin
g en
gage
men
t in
dis
cuss
ion
an
d pl
ann
ing
1B
est
prac
tice
NIC
E (
2014
) Q
ualit
y St
anda
rd Q
S61
ww
w.n
ice.
org.
uk/
guid
ance
/qs6
1
NIC
E G
uid
elin
e N
G15
(20
15)
Ant
imic
robi
al
stew
ards
hip:
sys
tem
s an
d pr
oces
ses
for
effe
ctiv
e an
tim
icro
bial
med
icin
e us
e w
ww
.nic
e.or
g.u
k/gu
idan
ce/N
G15
/ch
apte
r/2-
Impl
emen
tati
on-g
etti
ng-
star
ted
Cop
ies
of a
ll re
por
ts a
nd
asso
ciat
ed a
ctio
n p
lan
s in
res
pon
se t
o an
y ex
tern
al I
PC
focu
s vi
sits
/in
spec
tion
s (e
.g. f
rom
D
H, C
CG
, CQ
C, T
DA
, M
onit
or)
are
mad
e av
aila
ble
to t
he
com
mis
sion
er b
y th
e pr
ovid
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Cop
ies
of r
epor
ts s
ent
to c
omm
issi
oner
w
ith
in fi
ve w
orki
ng
days
of
the
prov
ider
re
ceiv
ing
the
rep
ort
Rep
orts
are
rec
eive
d1
Bes
t pr
acti
ce
Boa
rd-a
ppro
ved
ann
ual
re
por
t in
clu
des
deta
ils
on I
PC
tea
m r
esou
rces
An
nu
al r
epor
t in
clu
des
deta
ils o
n
serv
ice
and
spec
ialis
t IP
C (
nu
rse/
doct
or/
supp
ort
staf
f)
reso
urc
e re
quir
emen
ts a
nd
iden
tifi
es w
her
e ga
ps
or r
isks
exi
st
Incl
usi
on in
an
nu
al
rep
ort
IPC
res
ourc
es s
hou
ld
incl
ude
a r
atio
nal
e fo
r st
affi
ng
requ
irem
ents
, in
clu
din
g ‘s
upp
ort’
staf
f su
ch a
s ad
min
, sta
tist
ical
an
alys
is, e
tc. a
nd
both
ac
tual
an
d ag
reed
re
sou
rces
1B
est
prac
tice
This publication is being reviewed in 2019
18
InfectIon PreventIon and control commIssIonIng toolkIt
Return to contents
Qua
lity
requ
irem
ent
Thre
shol
d (r
epor
ting
ex
pect
atio
n)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/gui
danc
e
Ser
vice
use
r in
volv
emen
tSe
rvic
e u
sers
are
in
clu
ded
in I
PC
an
nu
al
prog
ram
me
de
velo
pmen
t, w
ith
pa
tien
t ex
per
ien
ce u
sed
to s
hap
e ac
tivi
ty
Serv
ice
use
r vi
ews
are
acti
vely
sou
ght
and
reco
mm
enda
tion
s in
corp
orat
ed w
her
e ap
prop
riat
e
Evid
ence
an
d d
etai
l of
par
tici
pati
on in
an
nu
al r
epor
t
1,3
Bes
t pr
acti
ce
Serv
ice
use
rs a
re
invo
lved
in t
he
shap
ing
and
impl
emen
tati
on o
f lo
cal p
rogr
amm
es t
o im
prov
e h
and
hygi
ene
of
both
sta
ff a
nd
serv
ice
use
rs in
all
sett
ings
Serv
ice
use
rs a
re
invo
lved
in h
and
hygi
ene
prog
ram
mes
An
nu
al s
um
mar
y of
h
and
hygi
ene
prog
ram
me
acti
vity
, in
clu
din
g u
ser
invo
lvem
ent
1,3
NIC
E (
2014
) Q
ualit
y St
anda
rd Q
S61
ww
w.n
ice.
org.
uk/
guid
ance
/qs6
1
Pati
ents
wit
h in
vasi
ve
devi
ces
such
as
uri
nar
y ca
thet
er, v
ascu
lar
acce
ss
devi
ce o
r en
tera
l fee
din
g tu
be a
nd
thei
r ca
rers
w
ho
hel
p th
em w
ith
th
is
equ
ipm
ent
are
give
n
info
rmat
ion
an
d ad
vice
ab
out
how
to
look
aft
er
the
devi
ce s
afel
y an
d ef
fect
ivel
y
Serv
ice
use
rs a
re
prov
ided
wit
h a
dvic
e an
d ar
e in
volv
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de
term
inin
g de
tail
of
info
rmat
ion
incl
ude
d
An
nu
al s
um
mar
y of
in
form
atio
n
avai
labl
e,
dist
ribu
tion
an
d ev
alu
atio
n in
clu
din
g pa
tien
t/ca
rer
feed
back
1,3
NIC
E (
2014
) Q
ualit
y St
anda
rd Q
S61
ww
w.n
ice.
org.
uk/
guid
ance
/qs6
1
NIC
E (
2012
) C
G 1
39 I
nfec
tion
: Pre
vent
ion
and
cont
rol
of h
ealt
hcar
e-as
soci
ated
infe
ctio
ns in
pri
mar
y an
d co
mm
unit
y ca
re
ww
w.n
ice.
org.
uk/
guid
ance
/cg1
39
MR
SA
, C. d
iffi
cile
and
oth
er s
igni
fica
nt H
CA
IsM
RSA
bac
tera
emia
cas
es
are
not
ified
by
prov
ider
to
com
mis
sion
er b
y n
ext
wor
kin
g da
y (r
efer
to
PIR
pro
cess
)
Not
ifica
tion
of
MR
SA
bact
erae
mia
Mon
thly
co
nfi
rmat
ion
of
per
cen
tage
of
case
s n
otifi
ed b
y n
ext
wor
kin
g da
y
1, 5
Bes
t pr
acti
ce
NH
S E
ngl
and
(201
4) Z
ero
tole
ranc
e
ww
w.e
ngl
and.
nh
s.u
k/pa
tien
tsaf
ety/
asso
ciat
ed-
infe
ctio
ns/
zero
-tol
eran
ce/This publication is being reviewed in 2019
Royal College of NuRsiNg aNd iNfeCtioN PReveNtioN soCiety
19 Return to contents
Qua
lity
requ
irem
ent
Thre
shol
d (r
epor
ting
ex
pect
atio
n)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/gui
danc
e
Th
e pr
ovid
er c
ontr
ibu
tes
to t
he
Post
In
fect
ion
R
evie
w (
PIR
) /
RC
A/‘
Lap
se in
car
e’
inve
stig
atio
ns
for
all
case
s of
HC
AI
Con
trib
uti
on t
o th
e P
IR p
roce
ss a
nd
imp
lem
enta
tion
of
acti
on p
lan
s an
d le
arn
ing
deri
ved
from
in
vest
igat
ion
rev
iew
s.
100%
att
enda
nce
at
inve
stig
atio
n
mee
tin
gs
Att
enda
nce
at
PIR
m
eeti
ngs
.
Mon
thly
rep
orti
ng
of a
ll M
RSA
cas
es
and
less
ons
lear
ned
.
Act
ion
pla
n r
epor
ts
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20
InfectIon PreventIon and control commIssIonIng toolkIt
Return to contents
Qua
lity
requ
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Thre
shol
d (r
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ex
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This publication is being reviewed in 2019
Royal College of NuRsiNg aNd iNfeCtioN PReveNtioN soCiety
21 Return to contents
Qua
lity
requ
irem
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Thre
shol
d (r
epor
ting
ex
pect
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Met
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of
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Six-
mon
thly
re
por
tin
g of
pro
gres
s in
str
ateg
y
Req
uir
emen
ts a
re fo
r lo
cal d
eter
min
atio
n
base
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pat
ien
t p
opu
lati
on a
nd
serv
ice
spec
ifica
tion
bu
t ca
n
incl
ude
th
e el
emen
ts
outl
ined
in A
ppen
dix
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1, 3
,5B
est
prac
tice
NIC
E (
2014
) Q
ualit
y St
anda
rd Q
S61
ww
w.n
ice.
org.
uk/
guid
ance
/qs6
1
NIC
E C
G 1
39 (
2012
) In
fect
ion:
Pre
vent
ion
and
cont
rol
of h
ealt
hcar
e-as
soci
ated
infe
ctio
ns in
pri
mar
y an
d co
mm
unit
y ca
re
ww
w.n
ice.
org.
uk/
guid
ance
/cg1
39
This publication is being reviewed in 2019
22
InfectIon PreventIon and control commIssIonIng toolkIt
Return to contents
Qua
lity
requ
irem
ent
Thre
shol
d (r
epor
ting
ex
pect
atio
n)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/gui
danc
e
Th
e pr
ovid
er h
as in
pl
ace
a st
rate
gy a
nd
syst
ems
to p
reve
nt
infe
ctio
ns
asso
ciat
ed
wit
h t
he
use
of
intr
aven
ous
(IV
) th
erap
y
Evid
ence
of
stra
tegy
an
d pr
oces
ses
in u
se
are
prov
ided
to
the
com
mis
sion
er
Six-
mon
thly
re
por
tin
g of
pro
gres
s in
str
ateg
y
IV t
her
apy
incl
ude
s dr
ug
adm
inis
trat
ion
(e.
g.
anti
biot
ics,
ch
emot
her
apy)
, IV
flu
id
ther
apy
or p
aren
tera
l n
utr
itio
n a
dmin
iste
red
via
an in
trav
ascu
lar
acce
ss d
evic
e.
Req
uir
emen
ts a
re fo
r lo
cal d
eter
min
atio
n
base
d on
pat
ien
t p
opu
lati
on a
nd
serv
ice
spec
ifica
tion
bu
t ca
n
incl
ude
ele
men
ts
incl
ude
d w
ith
in
App
endi
x 5
1B
est
prac
tice
NIC
E (
2014
) Q
ualit
y St
anda
rd Q
S61
ww
w.n
ice.
org.
uk/
guid
ance
/qs6
1
Th
e pr
ovid
er h
as in
pl
ace
a st
rate
gy a
nd
syst
ems
to p
reve
nt
infe
ctio
ns
asso
ciat
ed
wit
h t
he
use
of
ente
ral
feed
ing
Evid
ence
of
stra
tegy
an
d pr
oces
ses
in u
se
are
prov
ided
to
the
com
mis
sion
er
Six-
mon
thly
re
por
tin
g of
pro
gres
s in
str
ateg
y
Req
uir
emen
ts a
re fo
r lo
cal d
eter
min
atio
n
base
d on
pat
ien
t p
opu
lati
on a
nd
serv
ice
spec
ifica
tion
bu
t ca
n
incl
ude
th
e el
emen
ts
outl
ined
in A
ppen
dix
5
1,3
Bes
t pr
acti
ce
NIC
E C
G 1
39 (
2012
) In
fect
ion:
Pre
vent
ion
and
cont
rol
of h
ealt
hcar
e-as
soci
ated
infe
ctio
ns in
pri
mar
y an
d co
mm
unit
y ca
re
ww
w.n
ice.
org.
uk/
guid
ance
/cg1
39
Com
plia
nce
wit
h
infe
ctio
n p
reve
nti
on
care
bu
nd
les
(e.g
. hig
h
impa
ct in
terv
enti
ons
(HII
))
Mon
thly
rep
orti
ng
of
com
plia
nce
M
onth
ly
con
firm
atio
n o
f 10
0% c
ompl
ian
ce
Perc
enta
ge o
f co
mpl
ian
ce
and
met
hod
of
mea
sure
men
t fo
r lo
cal
dete
rmin
atio
n
1B
est
prac
tice
100%
pat
ien
ts is
olat
ed
as p
er a
gree
d pr
ovid
er
pol
icy/
adv
ice
from
IP
C
team
Rep
ort
com
plia
nce
w
ith
isol
atio
n p
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yQ
uar
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por
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clu
din
g ex
cep
tion
s of
var
iati
on t
o p
olic
y
Pro
vide
r or
gan
isat
ion
s sh
ould
con
side
r pr
esen
tati
on o
f da
ta t
o in
clu
de n
on-i
sola
tion
of
pati
ents
per
pat
ien
t be
d da
y
1B
est
prac
tice
Com
plia
nce
wit
h
prov
ider
’s h
and
hygi
ene
pol
icy
Bi-
mon
thly
rep
ort
Com
plia
nce
as
sura
nce
wit
h h
and
hygi
ene
pol
icy
Perc
enta
ge o
f co
mpl
ian
ce
and
met
hod
of
mea
sure
men
t fo
r lo
cal
dete
rmin
atio
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1N
ICE
(20
14)
Qua
lity
Stan
dard
QS6
1 w
ww
.nic
e.or
g.u
k/gu
idan
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S61/
chap
ter/
Lis
t-of
-qu
alit
y-st
atem
ents
This publication is being reviewed in 2019
Royal College of NuRsiNg aNd iNfeCtioN PReveNtioN soCiety
23 Return to contents
Qua
lity
requ
irem
ent
Thre
shol
d (r
epor
ting
ex
pect
atio
n)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/gui
danc
e
Loca
lly d
eter
min
ed I
PC
tr
ain
ing
prog
ram
me
is
deliv
ered
as
per
loca
lly
agre
ed p
lan
for
each
st
aff
grou
p
Bi-
ann
ual
rep
orts
an
d ev
alu
atio
n o
f tr
ain
ing
prog
ram
me
is
rece
ived
Bi-
ann
ual
rep
orti
ng
Perc
enta
ge o
f co
mpl
ian
ce
and
met
hod
of
mea
sure
men
t fo
r lo
cal
dete
rmin
atio
n
1,3
Alig
ns
wit
h D
H (
2015
) C
ode
of P
ract
ice
Pres
crib
ing
Th
e pr
ovid
er h
as o
r co
ntr
ibu
tes
to a
n
anti
biot
ic s
tew
ard
ship
pr
ogra
mm
e th
at s
pan
s ca
re s
etti
ngs
loca
lly
Evid
ence
of
atte
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at
rele
van
t m
eeti
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an
d co
ntr
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to
loca
l A
MS
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me
Rep
orti
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of
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ress
wit
h A
MS
prog
ram
me
Perc
enta
ge o
f co
mpl
ian
ce, m
eth
od o
f m
easu
rem
ent,
incl
usi
on
crit
eria
an
d fr
equ
ency
of
com
plia
nce
ass
essm
ent
for
loca
l det
erm
inat
ion
2,3
Bes
t pr
acti
ce
NIC
E G
uid
elin
e N
G15
(20
15)
Ant
imic
robi
al
stew
ards
hip:
sys
tem
s an
d pr
oces
ses
for
effe
ctiv
e an
tim
icro
bial
med
icin
e us
e w
ww
.nic
e.or
g.u
k/gu
idan
ce/N
G15
/ch
apte
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emen
tati
on-g
etti
ng-
star
ted
An
an
tibi
otic
pol
icy
is in
pl
ace
that
refl
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atio
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pre
scri
bin
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idan
ce
Pre
sen
ce o
f an
tibi
otic
p
olic
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ual
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of p
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pla
cePo
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inim
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two-
year
ly u
nle
ss n
ew
nat
ion
al g
uid
ance
issu
ed
2N
ICE
Gu
idel
ine
NG
15 (
2015
) A
ntim
icro
bial
st
ewar
dshi
p: s
yste
ms
and
proc
esse
s fo
r ef
fect
ive
anti
mic
robi
al m
edic
ine
use
ww
w.n
ice.
org.
uk/
guid
ance
/NG
15/c
hap
ter/
2-Im
plem
enta
tion
-get
tin
g-st
arte
d
Com
plia
nce
wit
h lo
cal
anti
biot
ic p
olic
ies
Rep
orti
ng
of
com
plia
nce
, in
clu
din
g if
th
ere
is e
vide
nce
of
just
ifiab
le c
linic
al
reas
ons
for
devi
atio
n
from
set
form
ula
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dit
of c
ompl
ian
ce
wit
h t
he
anti
biot
ic
pres
crib
ing
form
ula
ry
Perc
enta
ge o
f co
mpl
ian
ce, m
eth
od o
f m
easu
rem
ent,
incl
usi
on
crit
eria
an
d fr
equ
ency
of
com
plia
nce
ass
essm
ent
for
loca
l det
erm
inat
ion
2N
ICE
Gu
idel
ine
NG
15 (
2015
) A
ntim
icro
bial
st
ewar
dshi
p: s
yste
ms
and
proc
esse
s fo
r ef
fect
ive
anti
mic
robi
al m
edic
ine
use
ww
w.n
ice.
org.
uk/
guid
ance
/NG
15/c
hap
ter/
2-Im
plem
enta
tion
-get
tin
g-st
arte
d
NIC
E (
2014
) Q
ualit
y St
anda
rd Q
S61
ww
w.n
ice.
org.
uk/
guid
ance
/qs6
1
DH
(20
11)
Star
t SM
AR
T th
en F
ocus
w
ww
.gov
.uk/
gove
rnm
ent/
publ
icat
ion
s/an
tim
icro
bial
-st
ewar
dsh
ip-s
tart
-sm
art-
then
-foc
us
Pre
scri
bers
mee
t th
eir
prof
essi
onal
sta
nda
rds
of
edu
cati
on a
nd
com
pet
ency
An
nu
al r
epor
t of
tr
ain
ing
and
com
pet
ency
An
nu
al r
epor
t an
d an
alys
is a
gain
st
qual
ity
requ
irem
ent
Info
rmat
ion
sh
ould
be
prov
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on
th
e n
um
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of
dif
fere
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prof
essi
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gr
oups
rec
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trai
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d co
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th
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are
elig
ible
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blic
Hea
lth
En
glan
d (2
013)
Ant
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robi
al
pres
crib
ing
and
Stew
ards
hip
com
pete
ncie
s
ww
w.g
ov.u
k/go
vern
men
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ds/s
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chm
ent_
data
/file
/253
094/
AR
HA
Ipre
scrc
omp
eten
cies
__2_
This publication is being reviewed in 2019
24
InfectIon PreventIon and control commIssIonIng toolkIt
Return to contents
Qua
lity
requ
irem
ent
Thre
shol
d (r
epor
ting
ex
pect
atio
n)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/gui
danc
e
Hea
lth
car
e pr
ofes
sion
als
rece
ive
edu
cati
on a
s pa
rt
of t
he
prov
ider
’s
ongo
ing
trai
nin
g re
spon
sibi
lity
on
anti
mic
robi
al r
esis
tan
ce,
incl
udi
ng
best
pra
ctic
e in
med
icin
es
opti
mis
atio
n
An
nu
al r
epor
t of
tr
ain
ing
nu
mbe
rs a
nd
per
cen
tage
of
thos
e w
ho
hav
e co
mpl
eted
tr
ain
ing
Evid
ence
an
d d
etai
l of
par
tici
pati
on in
an
nu
al s
tate
men
t
Edu
cati
on s
hou
ld fo
cus
on a
n h
olis
tic
appr
oach
to
an
tim
icro
bial
age
nts
, in
clu
din
g th
erap
euti
c m
anag
emen
t, pr
escr
ibin
g an
d di
spen
sin
g ad
vice
to
pati
ents
2,3
Bes
t pr
acti
ce
NIC
E G
uid
elin
e N
G15
(20
15)
Ant
imic
robi
al
stew
ards
hip:
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tem
s an
d pr
oces
ses
for
effe
ctiv
e an
tim
icro
bial
med
icin
e us
e w
ww
.nic
e.or
g.u
k/gu
idan
ce/N
G15
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apte
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on-g
etti
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(20
13)
UK
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yea
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tim
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men
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th
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an
tim
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bial
pr
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Eu
rop
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An
tibi
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orld
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tibi
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Incl
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IPC
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ort
Evid
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an
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etai
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tici
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an
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Typ
e of
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rmin
atio
n2,
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Bes
t pr
acti
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EC
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site
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p://
ecdc
.eu
ropa
.eu
/en
/EA
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/Pag
es/
Hom
e.as
px
Th
e pr
ovid
er h
as in
pl
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a pl
an t
o ac
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al-p
rem
-gu
id-1
516.
This publication is being reviewed in 2019
Royal College of NuRsiNg aNd iNfeCtioN PReveNtioN soCiety
25 Return to contents
Qua
lity
requ
irem
ent
Thre
shol
d (r
epor
ting
ex
pect
atio
n)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/gui
danc
e
Th
e pr
ovid
er h
as in
pl
ace
a pl
an t
o ac
hie
ve a
re
duct
ion
in t
he
prop
orti
on o
f br
oad-
spec
tru
m a
nti
biot
ics
pres
crib
ed
Th
e pr
ovid
er c
an
dem
onst
rate
th
at t
he
nu
mbe
r of
ce
phal
osp
orin
s,
quin
olon
es a
nd
co-a
mox
icla
v as
a
per
cen
tage
of
the
tota
l nu
mbe
r of
an
tibi
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is
red
uce
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10%
or
belo
w t
he
curr
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med
ian
pro
por
tion
fo
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per
Qu
alit
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ail
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e of
act
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cal
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rmin
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n2
NH
S E
ngl
and
(201
5) Q
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rem
ium
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5/16
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ngl
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516.
Mon
itor
ing
Surg
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sit
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fect
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su
rvei
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pla
nn
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and
rep
orte
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A s
urv
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pr
ogra
mm
e is
in
plac
e to
mon
itor
su
rgic
al in
terv
enti
ons
un
dert
aken
in
seco
nda
ry c
are
Evid
ence
an
d d
etai
l of
su
rvei
llan
ce
prog
ram
me,
de
fin
itio
ns
and
data
Perc
enta
ge o
f co
mpl
ian
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and
met
hod
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mea
sure
men
t fo
r lo
cal
dete
rmin
atio
n a
nd
may
in
clu
de c
olla
bora
tion
w
ith
oth
er p
rovi
ders
.
Defi
nit
ion
of
surg
ical
pr
oced
ure
to
be d
efin
ed
loca
lly w
ith
co
mm
issi
oner
1B
est
prac
tice
Vacc
inat
ion
Rep
orti
ng
on
com
plia
nce
wit
h h
ealt
h
care
wor
ker
vacc
inat
ion
pr
ogra
mm
e
An
nu
al c
onfi
rmat
ion
of
% a
ctu
al n
um
bers
an
d ty
pes
of
vacc
inat
ion
aga
inst
el
igib
le s
taff
An
nu
al r
epor
tin
g in
clu
din
g ex
cep
tion
s of
var
iati
on t
o p
olic
y
Lin
ks t
o cr
iter
ion
10,
DH
(2
015)
Cod
e of
Pra
ctic
e1
Bes
t pr
acti
ce
This publication is being reviewed in 2019
26
InfectIon PreventIon and control commIssIonIng toolkIt
Return to contents
Qua
lity
requ
irem
ent
Thre
shol
d (r
epor
ting
ex
pect
atio
n)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/gui
danc
e
Pati
ents
iden
tifi
ed a
s el
igib
le fo
r va
ccin
atio
n
stat
us
are
asse
ssed
an
d h
ave
outs
tan
din
g va
ccin
atio
ns
offe
red
by
prov
ider
Rep
orti
ng
of n
um
ber
of p
atie
nts
fou
nd
to
be e
ligib
le fo
r va
ccin
atio
ns
agai
nst
to
tal p
atie
nt
pop
ula
tion
Bi-
ann
ual
rep
orti
ng
of n
um
ber
of
pati
ents
fou
nd
to b
e el
igib
le fo
r va
ccin
atio
ns
Rep
orti
ng
shou
ld in
clu
de
brea
kdow
n o
f va
ccin
atio
ns
outs
tan
din
g.
Vac
cin
atio
n is
re
com
men
ded
not
m
anda
ted
1B
est
prac
tice
Inte
rnat
ion
al L
onge
vity
Cen
tre
(201
3) A
dult
va
ccin
atio
n –
a ke
y co
mpo
nent
of h
ealt
hy a
gein
g
ww
w.il
cuk.
org.
uk/
inde
x.ph
p/pu
blic
atio
ns/
publ
icat
ion
_det
ails
/adu
lt_v
acci
nat
ion
_a_k
ey_
com
pon
ent_
of_h
ealt
hy_a
gein
g
Pu
blic
Hea
lth
En
glan
d (2
013)
Im
mun
isat
ion
agai
nst
infe
ctio
us d
isea
se (
Gre
en b
ook)
w
ww
.gov
.uk/
gove
rnm
ent/
colle
ctio
ns/
imm
un
isat
ion
-ag
ain
st-i
nfe
ctio
us-
dise
ase-
the-
gree
n-b
ook
This publication is being reviewed in 2019
Royal College of NuRsiNg aNd iNfeCtioN PReveNtioN soCiety
27 Return to contents
App
endi
x 2:
Infe
ctio
n pr
even
tion
and
con
trol
bas
ket o
f sug
gest
ed in
dica
tors
– p
rim
ary
and
com
mun
ity
care
The
term
pri
mar
y ca
re in
clud
es (b
ut is
not
lim
ited
to) t
he fo
llow
ing
exam
ples
of N
HS
heal
th c
are
serv
ices
, suc
h as
thos
e pr
ovid
ed b
y ge
nera
l pra
ctiti
oner
s, c
omm
unity
/dis
tric
t nu
rsin
g se
rvic
es, d
entis
ts, o
ptom
etri
sts,
hea
lth v
isiti
ng, s
choo
l nur
ses,
pod
iatr
ists
, inf
usio
n th
erap
y se
rvic
es (i
nclu
ding
OPA
T) a
nd se
xual
hea
lth se
rvic
es.
Qua
lity
re
quir
emen
tTh
resh
old
(rep
orti
ng
expe
ctat
ion)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(n
ote
whe
re s
peci
fic
guid
ance
is n
ot p
rese
nt th
is is
in
dica
ted
as ‘b
est p
ract
ice’
)
Am
biti
on in
dica
tors
Th
e pr
ovid
er h
as in
pl
ace
a st
rate
gy t
hat
de
scri
bes
its
visi
on
and
acti
ons
over
ti
me
to d
iagn
ose,
m
easu
re, p
reve
nt
and
man
age
pneu
mon
ia
Evid
ence
of
stra
tegy
, in
clu
din
g h
ow it
will
be
rev
iew
ed a
nd
eval
uat
ed
Evid
ence
of
stra
tegy
an
d im
plem
enta
tion
pl
an
Stra
tegy
sh
ould
incl
ude
th
e ro
le o
f m
ult
i-di
scip
linar
y st
akeh
olde
rs
and
com
mu
nic
atio
n
path
way
s. S
trat
egy
may
be
dev
elop
ed a
nd
impl
emen
ted
in
colla
bora
tion
wit
h o
ther
pr
ovid
er o
rgan
isat
ion
s
1B
est
prac
tice
NIC
E C
G19
1 (2
014)
Pne
umon
ia: D
iagn
osis
and
man
agem
ent
of c
omm
unit
y- a
nd h
ospi
tal-
acqu
ired
pne
umon
ia in
adu
lts
ww
w.n
ice.
org.
uk/
guid
ance
/CG
191
Parl
iam
enta
ry a
nd
Hea
lth
Ser
vice
s O
mbu
dsm
an (
2014
) T
ime
to A
ct, s
ever
e se
psis
: rap
id d
iagn
osis
and
tre
atm
ent
save
s liv
es w
ww
.om
buds
man
.org
.uk/
__da
ta/a
sset
s/pd
f_fi
le/0
004/
2266
6/FI
NA
L_S
epsi
s_R
epor
t_w
eb.p
df
Th
e pr
ovid
er h
as in
pl
ace
a st
rate
gy t
hat
de
scri
bes
its
visi
on
and
acti
ons
over
ti
me
to s
upp
ort
pati
ents
in t
he
prev
enti
on,
diag
nos
is a
nd
man
agem
ent
of
uri
nar
y tr
act
infe
ctio
ns,
incl
udi
ng
thos
e th
at a
re n
ot
rela
ted
to t
he
use
of
uri
nar
y ca
thet
ers
Evid
ence
of
stra
tegy
, in
clu
din
g h
ow it
will
be
rev
iew
ed a
nd
eval
uat
ed
Evid
ence
of
stra
tegy
an
d im
plem
enta
tion
pl
an
Stra
tegy
sh
ould
incl
ude
th
e ro
le o
f m
ult
i-di
scip
linar
y st
akeh
olde
rs
and
com
mu
nic
atio
n
path
way
s. S
trat
egy
may
be
dev
elop
ed a
nd
impl
emen
ted
in
colla
bora
tion
wit
h o
ther
pr
ovid
er o
rgan
isat
ion
s.
Not
e: m
ay a
lign
wit
h
prac
tice
indi
cato
rs o
n
falls
an
d C
AU
TI
(pag
e 33
)
1,5
Bes
t pr
acti
ce
NIC
E C
G54
(20
07)
Uri
nary
tra
ct in
fect
ion
in c
hild
ren:
D
iagn
osis
, tre
atm
ent a
nd lo
ng-t
erm
man
agem
ent
ww
w.n
ice.
org.
uk/
guid
ance
/cg5
4
NIC
E (
2014
) Q
ualit
y St
anda
rd I
nfec
tion
pre
vent
ion
and
Con
trol
QS6
1 w
ww
.nic
e.or
g.u
k/gu
idan
ce/q
s61
NIC
E C
G 1
39 (
2012
) In
fect
ion:
Pre
vent
ion
and
cont
rol o
f he
alth
care
-ass
ocia
ted
infe
ctio
ns in
pri
mar
y an
d co
mm
unit
y ca
re w
ww
.nic
e.or
g.u
k/gu
idan
ce/c
g139
Parl
iam
enta
ry a
nd
Hea
lth
Ser
vice
s O
mbu
dsm
an (
2014
)
Tim
e to
Act
, sev
ere
seps
is: r
apid
dia
gnos
is a
nd t
reat
men
t sa
ves
lives
ww
w.o
mbu
dsm
an.o
rg.u
k/__
data
/ass
ets/
pdf_
file
/000
4/22
666/
FIN
AL
_Sep
sis_
Rep
ort_
web
NIC
E (
2015
) Q
ualit
y St
anda
rd U
rina
ry t
ract
infe
ctio
ns in
ad
ults
QS9
0 w
ww
.nic
e.or
g.u
k/gu
idan
ce/q
s90
NIC
E (
2013
) Q
ualit
y St
anda
rd U
rina
ry t
ract
infe
ctio
n in
in
fant
s, c
hild
ren
and
youn
g pe
ople
und
er 1
6 Q
S36
w
ww
.nic
e.or
g.u
k/gu
idan
ce/q
s36
NIC
E G
uid
elin
e C
G16
1 (2
013)
Fal
ls: a
sses
smen
t and
pr
even
tion
of f
alls
in o
lder
peo
ple
ww
w.n
ice.
org.
uk/
guid
ance
/cg1
61 This publication is being reviewed in 2019
28
InfectIon PreventIon and control commIssIonIng toolkIt
Return to contents
Qua
lity
re
quir
emen
tTh
resh
old
(rep
orti
ng
expe
ctat
ion)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(not
e w
here
spe
cifi
c gu
idan
ce is
not
pre
sent
this
is in
dica
ted
as ‘b
est
prac
tice
’)
Th
e pr
ovid
er h
as in
pl
ace
a st
rate
gy t
hat
de
scri
bes
acti
ons
to
reco
gnis
e m
easu
re
and
man
age
susp
ecte
d ca
ses
of
seps
is
Evid
ence
of
stra
tegy
, in
clu
din
g h
ow it
will
be
rev
iew
ed a
nd
eval
uat
ed
Evid
ence
of
stra
tegy
an
d im
plem
enta
tion
p
lan
Stra
tegy
sh
ould
incl
ude
th
e ro
le o
f m
ult
i-di
scip
linar
y st
akeh
olde
rs
and
com
mu
nic
atio
n
path
way
s. S
trat
egy
may
be
dev
elop
ed a
nd
impl
emen
ted
in
colla
bora
tion
wit
h o
ther
pr
ovid
er o
rgan
isat
ion
s
1, 2
NH
S E
ngl
and
(201
5) C
omm
issi
onin
g fo
r qu
alit
y an
d in
nova
tion
(C
QU
IN)
Gui
danc
e fo
r 20
15/1
6
ww
w.e
ngl
and.
nh
s.u
k/w
p-co
nte
nt/
upl
oads
/201
5/03
/9-c
quin
-gu
id-2
015-
16.p
df
Parl
iam
enta
ry a
nd
Hea
lth
Ser
vice
s O
mbu
dsm
an (
2014
) T
ime
to A
ct, s
ever
e se
psis
: rap
id d
iagn
osis
and
tre
atm
ent
save
s liv
es w
ww
.om
buds
man
.org
.uk/
__da
ta/a
sset
s/pd
f_fi
le/0
004/
2266
6/FI
NA
L_S
epsi
s_R
epor
t_w
eb.p
df
Org
anis
atio
nal e
lem
ents
IPC
is in
clu
ded
as a
re
gula
r ag
enda
item
in
rel
evan
t pr
ovid
er
orga
nis
atio
n
mee
tin
gs
Rec
ord
of m
eeti
ngs
an
d IP
C t
opic
s d
iscu
ssed
Min
ute
s of
mee
tin
gsP
rovi
der
to d
eter
min
e w
hic
h m
eeti
ngs
will
ro
uti
nel
y in
clu
de I
PC
di
scu
ssio
n
1B
est
prac
tice
NIC
E (
2014
) Q
ualit
y St
anda
rd I
nfec
tion
pre
vent
ion
and
Con
trol
QS6
1 w
ww
.nic
e.or
g.u
k/gu
idan
ce/q
s61
Th
e or
gan
isat
ion
de
velo
ps a
nd
own
s a
boar
d-ap
prov
ed
HC
AI
redu
ctio
n
plan
an
d pr
ogre
ss is
re
por
ted
agai
nst
th
is
Qu
arte
rly
com
plia
nce
rep
orts
Qu
arte
rly
rece
ipt
of
rep
orts
det
ailin
g co
mpl
ian
ce a
nd
prog
ress
aga
inst
pl
an
Th
e pr
ovid
er m
ay w
ish
to
use
th
e C
ode
of P
ract
ice
to d
evel
op a
n I
PC
pla
n
1N
HS
En
glan
d St
anda
rd C
ontr
act 2
015/
16 a
nd 2
016/
17
ww
w.e
ngl
and.
nh
s.u
k/n
hs-
stan
dard
-con
trac
t/15
-16/
w
ww
.en
glan
d.n
hs.
uk/
nh
s-st
anda
rd-c
ontr
act/
16-1
7/
An
tim
icro
bial
st
ewar
dsh
ip (
AM
S)
(in
clu
din
g lo
cal
prog
ram
mes
an
d
surv
eilla
nce
) is
in
clu
ded
as a
reg
ula
r ag
enda
item
in
rele
van
t pr
ovid
er
orga
nis
atio
n
mee
tin
gs
Rec
ord
of m
eeti
ngs
an
d A
MS
top
ics
dis
cuss
ed
Min
ute
s of
mee
tin
gsP
rovi
der
to d
eter
min
e w
hic
h m
eeti
ngs
will
ro
uti
nel
y in
clu
de A
MS
disc
uss
ion
2B
est
prac
tice
NIC
E G
uid
elin
e N
G15
(20
15)
Ant
imic
robi
al s
tew
ards
hip:
sy
stem
s an
d pr
oces
ses
for
effe
ctiv
e an
tim
icro
bial
med
icin
e us
e w
ww
.nic
e.or
g.u
k/gu
idan
ce/N
G15
/ch
apte
r/2-
Impl
emen
tati
on-g
etti
ng-
star
ted
NIC
E (
2014
) Q
ualit
y St
anda
rd I
nfec
tion
pre
vent
ion
and
Con
trol
QS6
1 w
ww
.nic
e.or
g.u
k/gu
idan
ce/q
s61
Pro
vide
r ta
kes
into
ac
cou
nt
advi
ce fr
om
spec
ialis
t I
PC
an
d A
MS
prov
ider
/tea
ms
Doc
um
enta
tion
an
d de
tails
of
deci
sion
/re
med
ial a
ctio
n
Wh
ere
spec
ialis
t IP
C/
AM
S ad
vice
is n
ot
follo
wed
, th
e ra
tion
ale
and
deci
sion
is
docu
men
ted
and
disc
uss
ed a
t th
e re
leva
nt
mee
tin
g (s
ee t
wo
indi
cato
rs a
bove
)
1B
est
prac
tice
NIC
E G
uid
elin
e N
G15
(20
15)
Ant
imic
robi
al s
tew
ards
hip:
sy
stem
s an
d pr
oces
ses
for
effe
ctiv
e an
tim
icro
bial
med
icin
e us
e w
ww
.nic
e.or
g.u
k/gu
idan
ce/N
G15
/ch
apte
r/2-
Impl
emen
tati
on-g
etti
ng-
star
tedThis publication is being reviewed in 2019
Royal College of NuRsiNg aNd iNfeCtioN PReveNtioN soCiety
29 Return to contents
Qua
lity
re
quir
emen
tTh
resh
old
(rep
orti
ng
expe
ctat
ion)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(not
e w
here
spe
cifi
c gu
idan
ce is
not
pre
sent
this
is in
dica
ted
as ‘b
est
prac
tice
’)
Th
e or
gan
isat
ion
em
ploy
s or
has
su
ffici
ent
acce
ss t
o a
suit
ably
res
ourc
ed
and
qual
ified
In
fect
ion
Pre
ven
tion
an
d C
ontr
ol T
eam
(I
PC
T),
A
nti
mic
robi
al
Stew
ards
hip
(A
MS)
te
am o
r sp
ecia
list
prac
titi
oner
to
mee
t th
eir
nee
ds
Spec
ialis
t ad
vise
rs
clea
rly
iden
tifi
able
Rec
ord
of s
ervi
ce o
r co
ntr
act
for
prov
isio
n o
f IP
C
and
AM
S ad
vice
Con
trac
t m
ay b
e fo
r em
ploy
men
t or
adv
ice
and
shou
ld d
etai
l th
e n
um
ber
of h
ours
em
ploy
ed/c
ontr
acte
d,
role
des
crip
tion
, lin
es o
f co
mm
un
icat
ion
an
d go
vern
ance
str
uct
ure
s fo
r IP
C a
nd
wit
hin
pro
vide
r or
gan
isat
ion
1N
ICE
Gu
idel
ine
NG
15 (
2015
) A
ntim
icro
bial
ste
war
dshi
p:
syst
ems
and
proc
esse
s fo
r ef
fect
ive
anti
mic
robi
al m
edic
ine
use
ww
w.n
ice.
org.
uk/
guid
ance
/NG
15/c
hap
ter/
2-Im
plem
enta
tion
-get
tin
g-st
arte
d
Alig
ns
wit
h D
H (
2015
) C
ode
of P
ract
ice
crit
eria
th
ree
Pro
vide
r co
ntr
ibu
tes
to w
hol
e ec
onom
y st
rate
gic
plan
nin
g di
scu
ssio
n a
nd
deci
sion
mak
ing
on
HC
AI
redu
ctio
n/
AM
S
Rec
ord
of a
tten
dan
ce
and
con
trib
uti
onM
inu
tes
of m
eeti
ngs
Loca
l pro
fess
ion
al
net
wor
ks c
an b
e u
sed
as a
m
eth
od o
f de
mon
stra
tin
g en
gage
men
t in
dis
cuss
ion
an
d pl
ann
ing
1B
est
prac
tice
NIC
E (
2014
) Q
ualit
y St
anda
rd Q
S61
ww
w.n
ice.
org.
uk/
guid
ance
/qs6
1
NIC
E G
uid
elin
e N
G15
(20
15)
Ant
imic
robi
al s
tew
ards
hip:
sy
stem
s an
d pr
oces
ses
for
effe
ctiv
e an
tim
icro
bial
med
icin
e us
e w
ww
.nic
e.or
g.u
k/gu
idan
ce/N
G15
/ch
apte
r/2-
Impl
emen
tati
on-g
etti
ng-
star
ted
Cop
ies
of a
ll re
por
ts
and
asso
ciat
ed
acti
on p
lan
s in
re
spon
se t
o an
y ex
tern
al I
PC
focu
s vi
sits
/in
spec
tion
s (e
.g. f
rom
CC
G,
CQ
C)
are
mad
e av
aila
ble
to t
he
com
mis
sion
er b
y th
e pr
ovid
er
Cop
ies
of r
epor
ts
sen
t to
com
mis
sion
er
wit
hin
five
wor
kin
g da
ys o
f th
e pr
ovid
er
rece
ivin
g th
e re
por
t
Rep
orts
are
rec
eive
d1
Bes
t pr
acti
ce
This publication is being reviewed in 2019
30
InfectIon PreventIon and control commIssIonIng toolkIt
Return to contents
Qua
lity
re
quir
emen
tTh
resh
old
(rep
orti
ng
expe
ctat
ion)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(not
e w
here
spe
cifi
c gu
idan
ce is
not
pre
sent
this
is in
dica
ted
as ‘b
est
prac
tice
’)
Pra
ctic
es
com
mis
sion
ed t
o pr
ovid
e en
han
ced
serv
ices
, e.g
. nam
ed
GPs
for
care
hom
e/s
are
able
to
dem
onst
rate
ap
prop
riat
e tr
ain
ing
and
capa
city
Nam
ed s
taff
fully
aw
are
of c
lien
t gr
oup
nee
ds a
nd
pot
enti
al
surg
e re
quir
emen
ts
Serv
ice
spec
ifica
tion
, an
nu
al
revi
ews,
sta
ff
trai
nin
g re
cord
s,
surg
e pl
an
An
exa
mpl
e of
su
rge
requ
irem
ents
may
be
addi
tion
al c
apac
ity
requ
ired
for
flu
im
mu
nis
atio
n, o
utb
reak
s an
d w
inte
r co
ver
to a
void
h
ospi
tal a
dmis
sion
1B
est
prac
tice
Ser
vice
use
r in
volv
emen
tSe
rvic
e u
sers
are
in
clu
ded
in I
PC
an
nu
al p
rogr
amm
e
deve
lopm
ent,
wit
h
pati
ent
exp
erie
nce
u
sed
to s
hap
e ac
tivi
ty
Serv
ice
use
r vi
ews
are
acti
vely
sou
ght
and
reco
mm
end
atio
ns
inco
rpor
ated
wh
ere
appr
opri
ate
Evid
ence
an
d d
etai
l of
par
tici
pat
ion
in
ann
ual
rep
ort
1,3
Bes
t pr
acti
ce
Serv
ice
use
rs a
re
invo
lved
in t
he
shap
ing
and
impl
emen
tati
on o
f lo
cal p
rogr
amm
es t
o im
prov
e h
and
hygi
ene
of b
oth
sta
ff
and
serv
ice
use
rs in
al
l set
tin
gs
Serv
ice
use
rs a
re
invo
lved
in h
and
hygi
ene
prog
ram
mes
An
nu
al s
um
mar
y of
h
and
hygi
ene
prog
ram
me
acti
vity
in
clu
din
g u
ser
invo
lvem
ent
1,3
NIC
E (
2014
) Q
ualit
y St
anda
rd Q
S61
ww
w.n
ice.
org.
uk/
guid
ance
/qs6
1
NIC
E C
G 1
39 (
2012
) In
fect
ion:
Pre
vent
ion
and
cont
rol o
f he
alth
care
-ass
ocia
ted
infe
ctio
ns in
pri
mar
y an
d co
mm
unit
y ca
re w
ww
.nic
e.or
g.u
k/gu
idan
ce/c
g139
Peop
le w
ith
inva
sive
de
vice
s su
ch a
s a
uri
nar
y ca
thet
er,
vasc
ula
r ac
cess
de
vice
or
ente
ral
feed
ing
tube
an
d th
eir
care
rs w
ho
hel
p
them
wit
h t
his
eq
uip
men
t ar
e gi
ven
in
form
atio
n a
nd
advi
ce a
bou
t h
ow t
o lo
ok a
fter
th
e de
vice
sa
fely
an
d ef
fect
ivel
y
Serv
ice
use
rs a
re
prov
ided
wit
h a
dvic
e an
d a
re in
volv
ed in
de
term
inin
g de
tail
of
info
rmat
ion
in
clu
ded
An
nu
al s
um
mar
y of
in
form
atio
n
avai
labl
e,
dist
ribu
tion
an
d ev
alu
atio
n in
clu
din
g pa
tien
t/ca
rer
feed
back
1,3
NIC
E (
2014
) Q
ualit
y St
anda
rd Q
S61
ww
w.n
ice.
org.
uk/
guid
ance
/qs6
1
NIC
E C
G 1
39 (
2012
) In
fect
ion:
Pre
vent
ion
and
cont
rol o
f he
alth
care
-ass
ocia
ted
infe
ctio
ns in
pri
mar
y an
d co
mm
unit
y ca
re w
ww
.nic
e.or
g.u
k/gu
idan
ce/c
g139
This publication is being reviewed in 2019
Royal College of NuRsiNg aNd iNfeCtioN PReveNtioN soCiety
31 Return to contents
Qua
lity
re
quir
emen
tTh
resh
old
(rep
orti
ng
expe
ctat
ion)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(not
e w
here
spe
cifi
c gu
idan
ce is
not
pre
sent
this
is in
dica
ted
as ‘b
est
prac
tice
’)
MR
SA
and
C. d
iffi
cile
and
oth
er s
igni
fica
nt H
CA
IsC
ontr
ibu
tion
to
the
Post
In
fect
ion
R
evie
w/R
CA
/‘L
apse
in
car
e’
inve
stig
atio
ns
for
all
case
s of
HC
AI
Con
trib
uti
on t
o th
e P
IR p
roce
ss a
nd
im
plem
enta
tion
of
acti
on p
lan
s an
d le
arn
ing
deri
ved
from
inve
stig
atio
n
revi
ews.
100%
att
enda
nce
at
inve
stig
atio
n
mee
tin
gs
Att
end
ance
at
PIR
m
eeti
ngs
.
Act
ion
pla
n r
epor
ts
are
rece
ived
an
d u
pdat
ed r
egu
larl
y,
wit
h le
arn
ing
shar
ed
acro
ss t
he
orga
nis
atio
n
Wit
h e
xcep
tion
s of
M
RSA
bac
tera
emia
an
d C
. dif
ficile
infe
ctio
n,
oth
er H
CA
Is t
hat
req
uir
e in
vest
igat
ion
are
to
be
dete
rmin
ed lo
cally
1N
HS
En
glan
d (2
014)
Zer
o to
lera
nce
ww
w.e
ngl
and.
nh
s.u
k/pa
tien
tsaf
ety/
asso
ciat
ed-i
nfe
ctio
ns/
zero
-tol
eran
ce/
NH
S E
ngl
and
(201
5) C
lost
ridi
um
dif
fici
le in
fect
ion
obje
ctiv
es
for
NH
S or
gani
sati
ons
in 2
015/
16 a
nd g
uida
nce
on s
anct
ion
impl
emen
tati
on
ww
w.e
ngl
and.
nh
s.u
k/w
p-co
nte
nt/
upl
oads
/201
5/02
/cl
ostr
idm
-dif
fici
le-i
nfe
ct-o
bjct
-15-
16-g
uid
-feb
15.p
df
Com
plia
nce
wit
h
loca
lly a
gree
d M
RSA
ca
re p
athw
ay
Qu
arte
rly
con
firm
atio
n o
f p
erce
nta
ge o
f M
RSA
-pos
itiv
e pa
tien
ts w
ho
follo
w
and
com
ple
te t
he
MR
SA c
are
path
way
Qu
arte
rly
rece
ipt
of
MR
SA c
are
path
way
co
mpl
ian
ce d
ata
Car
e pa
thw
ays
shou
ld b
e de
fin
ed lo
cally
an
d al
l pr
ovid
ers
shou
ld b
e aw
are
of t
hes
e an
d co
mpl
y w
ith
th
em.
Con
side
r in
clu
sion
of
audi
t of
flag
gin
g of
M
RSA
sta
tus
acro
ss a
ll pa
tien
t ad
min
istr
atio
n
syst
ems
acro
ss t
he
path
way
.
Perc
enta
ge o
f co
mpl
ian
ce
and
met
hod
of
mea
sure
men
t fo
r lo
cal
dete
rmin
atio
n
1N
HS
En
glan
d (2
014)
Zer
o to
lera
nce
ww
w.e
ngl
and.
nh
s.u
k/pa
tien
tsaf
ety/
asso
ciat
ed-i
nfe
ctio
ns/
zero
-tol
eran
ce/
This publication is being reviewed in 2019
32
InfectIon PreventIon and control commIssIonIng toolkIt
Return to contents
Qua
lity
re
quir
emen
tTh
resh
old
(rep
orti
ng
expe
ctat
ion)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(not
e w
here
spe
cifi
c gu
idan
ce is
not
pre
sent
this
is in
dica
ted
as ‘b
est
prac
tice
’)
Com
plia
nce
wit
h
loca
lly a
gree
d C
. di
ffici
le c
are
path
way
Qu
arte
rly
con
firm
atio
n o
f p
erce
nt
of C
. dif
ficile
p
atie
nts
wh
o fo
llow
an
d co
mpl
ete
the
care
pat
hway
Qu
arte
rly
rece
ipt
of
C. d
iffic
ile c
are
pat
hway
com
plia
nce
d
ata
Car
e pa
thw
ays
shou
ld b
e de
fin
ed lo
cally
an
d al
l pr
ovid
ers
shou
ld b
e aw
are
of t
hem
an
d co
ntr
ibu
te w
her
e re
leva
nt.
Con
side
r in
clu
sion
of
audi
t of
fl
aggi
ng
of C
. dif
ficile
st
atu
s ac
ross
all
pati
ent
adm
inis
trat
ion
sys
tem
s ac
ross
th
e pa
thw
ay.
Perc
enta
ge o
f co
mpl
ian
ce
and
met
hod
of
mea
sure
men
t fo
r lo
cal
dete
rmin
atio
n
1B
est
prac
tice
Pro
vide
r co
ntr
ibu
tes
to r
evie
w o
f al
l CD
I ca
ses
if in
volv
ed in
pr
ovis
ion
of
care
to
pati
ent
100%
com
plia
nce
w
ith
invo
lvem
ent
in
revi
ew o
f an
y C
DI
case
th
at t
he
prov
ider
is a
ssoc
iate
d w
ith
Qu
arte
rly
subm
issi
on o
f ev
iden
ce
dem
onst
rati
ng
prov
ider
in
volv
emen
t in
re
view
mee
tin
gs a
nd
prog
ress
wit
h
acti
ons
Det
ail o
f m
easu
rem
ent
met
hod
to
be d
eter
min
ed
loca
lly
1N
HS
En
glan
d (2
015)
Clo
stri
diu
m d
iffi
cile
infe
ctio
n ob
ject
ives
fo
r N
HS
orga
nisa
tion
s in
201
5/16
and
gui
danc
e on
san
ctio
n im
plem
enta
tion
at
ww
w.e
ngl
and.
nh
s.u
k/w
p-co
nte
nt/
upl
oads
/201
5/02
/clo
stri
dm-d
iffi
cile
-in
fect
-obj
ct-1
5-16
-gu
id-f
eb15
Seri
ous
inci
den
ts
occu
rrin
g in
pri
mar
y ca
re a
re r
epor
ted
to
the
com
mis
sion
er
wit
hin
on
e w
orki
ng
day
Not
ifica
tion
of
inci
den
t to
co
mm
issi
oner
wit
hin
tw
o w
orki
ng
days
Qu
arte
rly
rep
orti
ng
Defi
nit
ion
of
seri
ous
inci
den
t to
be
defi
ned
by
prov
ider
follo
win
g ag
reem
ent
wit
h
com
mis
sion
er.
Ver
ifica
tion
mea
sure
–
STE
IS, N
RL
S, R
CA
, P
IR, p
atie
nt
com
plai
nts
1H
PA (
2012
) H
ealt
hcar
e as
soci
ated
infe
ctio
n op
erat
iona
l gu
idan
ce a
nd s
tand
ards
for
heal
th p
rote
ctio
n un
its
w
ww
.gov
.uk/
gove
rnm
ent/
publ
icat
ion
s/h
ealt
hca
re-
asso
ciat
ed-i
nfe
ctio
n-h
cai-
oper
atio
nal
-gu
idan
ce-a
nd
-st
anda
rds
NH
S E
ngl
and
(201
5) S
erio
us in
cide
nt fr
amew
ork
w
ww
.en
glan
d.n
hs.
uk/
pati
ents
afet
y/se
riou
s-in
cide
nt/
IPC
prac
tice
Th
e or
gan
isat
ion
has
an
IP
C l
ink
prac
titi
oner
pr
ogra
mm
e in
pla
ce
Syst
em is
in p
lace
an
d fu
nct
ion
ing
Bi-
ann
ual
rep
orti
ng
of li
nk
prac
titi
oner
ac
tivi
ty
1B
est
prac
tice
RC
N (
2011
) R
CN
link
nur
se fr
amew
ork
ww
w2.
rcn
.org
.uk/
__da
ta/a
sset
s/pd
f_fi
le/0
006/
4815
15/0
0431
0.pd
fThis publication is being reviewed in 2019
Royal College of NuRsiNg aNd iNfeCtioN PReveNtioN soCiety
33 Return to contents
Qua
lity
re
quir
emen
tTh
resh
old
(rep
orti
ng
expe
ctat
ion)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(not
e w
here
spe
cifi
c gu
idan
ce is
not
pre
sent
this
is in
dica
ted
as ‘b
est
prac
tice
’)
Th
e pr
ovid
er h
as in
pl
ace
a st
rate
gy a
nd
syst
ems
to p
reve
nt
infe
ctio
ns
asso
ciat
ed
wit
h t
he
use
of
intr
aven
ous
(IV
) th
erap
y
Evid
ence
of
stra
tegy
an
d pr
oces
ses
in u
se
are
prov
ided
to
the
com
mis
sion
er
Six-
mon
thly
re
por
tin
g of
pr
ogre
ss in
str
ateg
y
IV t
her
apy
incl
ude
s dr
ug
adm
inis
trat
ion
(e.
g.
anti
biot
ics,
ch
emot
her
apy)
, IV
flu
id
ther
apy
or p
aren
tera
l n
utr
itio
n a
dmin
iste
red
via
an in
trav
ascu
lar
acce
ss d
evic
e.
Req
uir
emen
ts a
re fo
r lo
cal d
eter
min
atio
n
base
d on
pat
ien
t p
opu
lati
on a
nd
serv
ice
spec
ifica
tion
bu
t ca
n
incl
ude
ele
men
ts
incl
ude
d w
ith
in
App
endi
x 5
1B
est
prac
tice
NIC
E (
2014
) Q
ualit
y St
anda
rd Q
S61
w
ww
.nic
e.or
g.u
k/gu
idan
ce/q
s61
Th
e pr
ovid
er h
as in
pl
ace
a st
rate
gy a
nd
syst
ems
to p
reve
nt
infe
ctio
ns
asso
ciat
ed
wit
h t
he
use
of
ente
ral f
eedi
ng
Evid
ence
of
stra
tegy
an
d p
roce
sses
in u
se
are
prov
ided
to
the
com
mis
sion
er
Six-
mon
thly
re
por
tin
g of
pr
ogre
ss in
str
ateg
y
Req
uir
emen
ts a
re fo
r lo
cal d
eter
min
atio
n
base
d on
pat
ien
t p
opu
lati
on a
nd
serv
ice
spec
ifica
tion
bu
t ca
n
incl
ude
th
e el
emen
ts
outl
ined
in A
ppen
dix
5
1,3
Bes
t pr
acti
ce
NIC
E C
G 1
39 (
2012
) In
fect
ion:
Pre
vent
ion
and
cont
rol o
f he
alth
care
-ass
ocia
ted
infe
ctio
ns in
pri
mar
y an
d co
mm
unit
y ca
re w
ww
.nic
e.or
g.u
k/gu
idan
ce/c
g139
Th
e pr
ovid
er h
as in
pl
ace
a st
rate
gy a
nd
syst
ems
to e
nsu
re t
he
prev
enti
on a
nd
reco
gnit
ion
of
cath
eter
-ass
ocia
ted
uri
nar
y tr
act
infe
ctio
ns
(CA
UT
I)
Evid
ence
of
stra
tegy
an
d p
roce
sses
in u
se
are
prov
ided
to
the
com
mis
sion
er
Six-
mon
thly
re
por
tin
g of
pr
ogre
ss in
str
ateg
y
Req
uir
emen
ts a
re fo
r lo
cal d
eter
min
atio
n
base
d on
pat
ien
t p
opu
lati
on a
nd
serv
ice
spec
ifica
tion
bu
t ca
n
incl
ude
th
e el
emen
ts
outl
ined
in A
ppen
dix
5
1, 3
,5B
est
prac
tice
NIC
E (
2014
) Q
ualit
y St
anda
rd Q
S61
w
ww
.nic
e.or
g.u
k/gu
idan
ce/q
s61
NIC
E C
G 1
39 (
2012
) In
fect
ion:
Pre
vent
ion
and
cont
rol o
f he
alth
care
-ass
ocia
ted
infe
ctio
ns in
pri
mar
y an
d co
mm
unit
y ca
re w
ww
.nic
e.or
g.u
k/gu
idan
ce/c
g139
All
staf
f h
ave
acce
ss
to r
esou
rces
to
supp
ort
han
d hy
gien
e at
th
e p
oin
t of
car
e w
hen
in
dica
ted
Evid
ence
of
how
re
sou
rces
are
se
lect
ed, p
rovi
ded
and
use
d in
pra
ctic
e
Six-
mon
thly
rev
iew
an
d e
valu
atio
n o
f pr
odu
ct u
se
Req
uir
emen
ts a
re fo
r lo
cal d
eter
min
atio
n
base
d on
pat
ien
t p
opu
lati
on a
nd
serv
ice
sett
ing
1N
ICE
(20
14)
Qua
lity
Stan
dard
QS6
1
ww
w.n
ice.
org.
uk/
guid
ance
/qs6
1
NIC
E C
G 1
39 (
2012
) In
fect
ion:
Pre
vent
ion
and
cont
rol o
f he
alth
care
-ass
ocia
ted
infe
ctio
ns in
pri
mar
y an
d co
mm
unit
y ca
re w
ww
.nic
e.or
g.u
k/gu
idan
ce/c
g139
This publication is being reviewed in 2019
34
InfectIon PreventIon and control commIssIonIng toolkIt
Return to contents
Qua
lity
re
quir
emen
tTh
resh
old
(rep
orti
ng
expe
ctat
ion)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(not
e w
here
spe
cifi
c gu
idan
ce is
not
pre
sent
this
is in
dica
ted
as ‘b
est
prac
tice
’)
Pres
crib
ing
Th
e pr
ovid
er h
as o
r co
ntr
ibu
tes
to a
n
anti
biot
ic
stew
ards
hip
pr
ogra
mm
e th
at
span
s ca
re s
etti
ngs
lo
cally
Evid
ence
of
atte
nda
nce
at
rele
van
t m
eeti
ngs
an
d co
ntr
ibu
tion
to
loca
l AM
S pr
ogra
mm
e
Rep
orti
ng
of
prog
ress
wit
h A
MS
prog
ram
me
Perc
enta
ge o
f co
mpl
ian
ce, m
eth
od o
f m
easu
rem
ent,
incl
usi
on
crit
eria
an
d fr
equ
ency
of
com
plia
nce
ass
essm
ent
for
loca
l det
erm
inat
ion
2,3
Bes
t pr
acti
ce
NIC
E G
uid
elin
e N
G15
(20
15)
Ant
imic
robi
al s
tew
ards
hip:
sy
stem
s an
d pr
oces
ses
for
effe
ctiv
e an
tim
icro
bial
med
icin
e us
e w
ww
.nic
e.or
g.u
k/gu
idan
ce/N
G15
/ch
apte
r/2-
Impl
emen
tati
on-g
etti
ng-
star
ted
An
an
tibi
otic
pol
icy/
guid
elin
e is
in p
lace
th
at r
eflec
ts n
atio
nal
pr
escr
ibin
g gu
idan
ce
Pre
sen
ce o
f an
tibi
otic
pol
icy
An
nu
al
con
firm
atio
n o
f p
olic
y in
pla
ce
Polic
y sh
ould
be
revi
ewed
min
imu
m o
f tw
o-ye
arly
un
less
new
n
atio
nal
gu
idan
ce is
sued
2N
ICE
Gu
idel
ine
NG
15 (
2015
) A
ntim
icro
bial
ste
war
dshi
p:
syst
ems
and
proc
esse
s fo
r ef
fect
ive
anti
mic
robi
al m
edic
ine
use
ww
w.n
ice.
org.
uk/
guid
ance
/NG
15/c
hap
ter/
2-Im
plem
enta
tion
-get
tin
g-st
arte
dC
ompl
ian
ce w
ith
lo
cal a
nti
biot
ic
pol
icie
s/gu
idel
ines
Rep
orti
ng
of
com
plia
nce
, in
clu
din
g if
th
ere
is
evid
ence
of
just
ifiab
le c
linic
al
reas
ons
for
devi
atio
n
from
set
form
ula
ry
Au
dit
of c
ompl
ian
ce
wit
h t
he
anti
biot
ic
pres
crib
ing
form
ula
ry
Perc
enta
ge o
f co
mpl
ian
ce, m
eth
od o
f m
easu
rem
ent,
incl
usi
on
crit
eria
an
d fr
equ
ency
of
com
plia
nce
ass
essm
ent
for
loca
l det
erm
inat
ion
2,3
RC
GP
TA
RG
ET
ant
ibio
tic
tool
kit
ww
w.r
cgp.
org.
uk/
targ
etan
tibi
otic
s/
NIC
E G
uid
elin
e N
G15
(20
15)
Ant
imic
robi
al s
tew
ards
hip:
sy
stem
s an
d pr
oces
ses
for
effe
ctiv
e an
tim
icro
bial
med
icin
e us
e w
ww
.nic
e.or
g.u
k/gu
idan
ce/N
G15
/ch
apte
r/2-
Impl
emen
tati
on-g
etti
ng-
star
ted
NIC
E (
2014
) Q
ualit
y St
anda
rd Q
S61
w
ww
.nic
e.or
g.u
k/gu
idan
ce/q
s61
Pre
scri
bers
mee
t th
eir
prof
essi
onal
st
anda
rds
of
edu
cati
on a
nd
com
pet
ency
An
nu
al r
epor
t of
tr
ain
ing
and
co
mp
eten
cy
An
nu
al r
epor
t an
d
anal
ysis
aga
inst
qu
alit
y re
quir
emen
t
Info
rmat
ion
sh
ould
be
prov
ided
on
th
e n
um
bers
of
dif
fere
nt
prof
essi
onal
gr
oups
rec
eivi
ng
trai
nin
g an
d co
mp
eten
cy
asse
ssm
ent
com
pare
d to
th
ose
that
are
elig
ible
2,3
Pu
blic
Hea
lth
En
glan
d (2
013)
Ant
imic
robi
al p
resc
ribi
ng a
nd
stew
ards
hip
com
pete
ncie
s w
ww
.gov
.uk/
gove
rnm
ent/
up
load
s/sy
stem
/upl
oads
/att
ach
men
t_da
ta/fi
le/2
5309
4/A
RH
AIp
resc
rcom
pet
enci
es__
2_.p
df
Hea
lth
car
e pr
ofes
sion
als
rece
ive
edu
cati
on a
s pa
rt o
f th
e pr
ovid
ers,
on
goin
g tr
ain
ing
resp
onsi
bilit
y on
an
tim
icro
bial
re
sist
ance
, in
clu
din
g be
st p
ract
ice
in
med
icin
es
opti
mis
atio
n
An
nu
al r
epor
t of
tr
ain
ing
nu
mbe
rs
and
per
cen
tage
of
thos
e w
ho
hav
e co
mp
lete
d tr
ain
ing
Evid
ence
an
d de
tail
of p
arti
cipa
tion
in
ann
ual
sta
tem
ent
Edu
cati
on s
hou
ld fo
cus
on a
n h
olis
tic
appr
oach
to
an
tim
icro
bial
age
nts
, in
clu
din
g th
erap
euti
c m
anag
emen
t, pr
escr
ibin
g an
d di
spen
sin
g ad
vice
to
pati
ents
2,3
Bes
t pr
acti
ce
NIC
E G
uid
elin
e N
G15
(20
15)
Ant
imic
robi
al s
tew
ards
hip:
sy
stem
s an
d pr
oces
ses
for
effe
ctiv
e an
tim
icro
bial
med
icin
e us
e w
ww
.nic
e.or
g.u
k/gu
idan
ce/N
G15
/ch
apte
r/2-
Impl
emen
tati
on-g
etti
ng-
star
ted
DH
(20
13)
UK
five
yea
r an
tim
icro
bial
res
ista
nce
stra
tegy
20
13-8
ww
w.g
ov.u
k/go
vern
men
t/pu
blic
atio
ns/
uk-
5-ye
ar-
anti
mic
robi
al-r
esis
tan
ce-s
trat
egy-
2013
-to-
2018
Hea
lth
Edu
cati
on E
ngl
and
(201
5) P
reve
ntio
n an
d pu
blic
he
alth
act
ion
plan
htt
ps:/
/hee
.nh
s.u
k/ou
r-w
ork/
hos
pit
als-
prim
ary-
com
mu
nit
y-ca
re/p
reve
nti
on-p
ubl
ic-h
ealt
h-
wel
lbei
ng-
0
This publication is being reviewed in 2019
Royal College of NuRsiNg aNd iNfeCtioN PReveNtioN soCiety
35 Return to contents
Qua
lity
re
quir
emen
tTh
resh
old
(rep
orti
ng
expe
ctat
ion)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(not
e w
here
spe
cifi
c gu
idan
ce is
not
pre
sent
this
is in
dica
ted
as ‘b
est
prac
tice
’)
Th
e pr
ovid
er h
as a
sy
stem
in p
lace
to
mea
sure
an
d m
onit
or a
nti
biot
ic
pres
crib
ing
prac
tice
s
An
nu
al r
evie
wA
nn
ual
rep
ort
and
an
alys
is a
gain
st
qual
ity
requ
irem
ent
App
lies
to d
enti
sts
and
oth
ers
wh
o ca
n p
resc
ribe
bu
t w
ho
aren
’t a
ffec
ted
by Q
ual
ity
Pre
miu
m
2,3
NIC
E G
uid
elin
e N
G15
(20
15)
Ant
imic
robi
al s
tew
ards
hip:
sy
stem
s an
d pr
oces
ses
for
effe
ctiv
e an
tim
icro
bial
med
icin
e us
e w
ww
.nic
e.or
g.u
k/gu
idan
ce/N
G15
/ch
apte
r/2-
Impl
emen
tati
on-g
etti
ng-
star
ted
Th
e pr
ovid
er
part
icip
ates
an
nu
ally
in
aw
aren
ess-
rais
ing
prog
ram
mes
th
at
supp
ort
best
pra
ctic
e in
an
tim
icro
bial
pr
escr
ibin
g/u
se, e
.g.
Eu
rop
ean
An
tibi
otic
A
war
enes
s D
ay
(EA
AD
) an
d W
orld
A
nti
biot
ic A
war
enes
s W
eek
(WA
AW
)
Incl
usi
on in
an
nu
al
stat
emen
tEv
iden
ce a
nd
deta
il of
par
tici
pati
on in
an
nu
al s
tate
men
t
Typ
e of
act
ivit
y fo
r lo
cal
dete
rmin
atio
n2,
3,7
Bes
t pr
acti
ce
EC
DC
web
site
htt
p://
ecdc
.eu
ropa
.eu
/en
/Pag
es/h
ome.
asp
x
Th
e pr
ovid
er h
as in
pl
ace
a pl
an t
o ac
hie
ve a
red
uct
ion
in
th
e n
um
ber
of
anti
biot
ics
pres
crib
ed
The
pro
vide
r ca
n
dem
onst
rate
a 1
% o
r gr
eate
r re
duct
ion
in
the
nu
mbe
r of
an
tibi
otic
s pr
escr
ibed
in
pri
mar
y ca
re
acro
ss th
e C
CG
As
per
qu
alit
y pr
emiu
m d
etai
l2
NH
S E
ngl
and
(201
5) Q
ualit
y P
rem
ium
: 201
5/16
Gui
danc
e fo
r C
CG
s w
ww
.en
glan
d.n
hs.
uk/
wp-
con
ten
t/u
ploa
ds/2
015/
04/q
ual
-pre
m-g
uid
-151
6.pd
f
Th
e pr
ovid
er h
as in
pl
ace
a pl
an t
o ac
hie
ve a
red
uct
ion
in
th
e pr
opor
tion
of
broa
d-sp
ectr
um
an
tibi
otic
s pr
escr
ibed
The
pro
vide
r ca
n
dem
onst
rate
that
the
nu
mbe
r of
ce
phal
ospo
rin
s,
quin
olon
es a
nd
co-a
mox
icla
v as
a
perc
enta
ge o
f th
e to
tal n
um
ber
of
anti
biot
ics
pres
crib
ed
is r
edu
ced
by 1
0% o
r be
low
the
curr
ent
med
ian
pro
port
ion
fo
r E
ngl
ish
CC
Gs
(whi
chev
er is
met
fi
rst)
As
per
qu
alit
y pr
emiu
m d
etai
l2
NH
S E
ngl
and
(201
5) Q
ualit
y P
rem
ium
: 201
5/16
Gui
danc
e fo
r C
CG
s w
ww
.en
glan
d.n
hs.
uk/
wp-
con
ten
t/u
ploa
ds/2
015/
04/q
ual
-pre
m-g
uid
-151
6.pd
f
This publication is being reviewed in 2019
36
InfectIon PreventIon and control commIssIonIng toolkIt
Return to contents
Qua
lity
re
quir
emen
tTh
resh
old
(rep
orti
ng
expe
ctat
ion)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(not
e w
here
spe
cifi
c gu
idan
ce is
not
pre
sent
this
is in
dica
ted
as ‘b
est
prac
tice
’)
Mon
itor
ing
Wh
ere
min
or
surg
ery
is
un
dert
aken
, su
rgic
al
site
infe
ctio
n
surv
eilla
nce
is
plan
ned
an
d re
por
ted
A s
urv
eilla
nce
pr
ogra
mm
e is
in
pla
ce t
o m
onit
or
surg
ical
in
terv
enti
ons
un
dert
aken
in
prim
ary
care
Evid
ence
an
d d
etai
l of
su
rvei
llan
ce
prog
ram
me,
de
fin
itio
ns
and
data
Perc
enta
ge o
f co
mpl
ian
ce
and
met
hod
of
mea
sure
men
t fo
r lo
cal
dete
rmin
atio
n a
nd
may
in
clu
de c
olla
bora
tion
w
ith
oth
er p
rovi
ders
.
Defi
nit
ion
of
surg
ical
pr
oced
ure
to
be d
efin
ed
loca
lly w
ith
co
mm
issi
oner
1B
est
prac
tice
Vacc
inat
ions
R
epor
tin
g on
co
mpl
ian
ce o
f h
ealt
h
care
wor
ker
vacc
inat
ion
pr
ogra
mm
e
An
nu
al c
onfi
rmat
ion
of
per
cen
tage
of
actu
al n
um
bers
an
d ty
pes
of
vacc
inat
ion
ag
ain
st e
ligib
le s
taff
An
nu
al r
epor
tin
g in
clu
din
g ex
cep
tion
s of
var
iati
on t
o p
olic
y
Vac
cin
atio
n is
re
com
men
ded
not
m
anda
ted
1A
lign
s w
ith
DH
(20
15)
Cod
e of
Pra
ctic
e cr
iter
ion
10
Pati
ents
iden
tifi
ed a
s el
igib
le fo
r va
ccin
atio
n s
tatu
s ar
e as
sess
ed a
nd
hav
e ou
tsta
ndi
ng
vacc
inat
ion
s of
fere
d by
pro
vide
r
Rep
orti
ng
of n
um
ber
of v
acci
nat
ion
s of
fere
d an
d ad
min
iste
red
Bi-
ann
ual
rep
orti
ng
Rep
orti
ng
to in
clu
de
brea
kdow
n p
er
vacc
inat
ion
cat
egor
y
1B
est
prac
tice
Inte
rnat
ion
al L
onge
vity
Cen
tre
(201
3) A
dult
vac
cina
tion
– a
ke
y co
mpo
nent
of h
ealt
hy a
gein
g w
ww
.ilcu
k.or
g.u
k/in
dex.
php/
publ
icat
ion
s/pu
blic
atio
n_d
etai
ls/a
dult
_vac
cin
atio
n_a
_ke
y_co
mp
onen
t_of
_hea
lthy
_age
ing
Pu
blic
Hea
lth
En
glan
d (2
014)
Im
mun
isat
ion
agai
nst
infe
ctio
us d
isea
se (
Gre
en b
ook)
ww
w.g
ov.u
k/go
vern
men
t/co
llect
ion
s/im
mu
nis
atio
n-a
gain
st-i
nfe
ctio
us-
dise
ase-
the-
gree
n-b
ook
This publication is being reviewed in 2019
Royal College of NuRsiNg aNd iNfeCtioN PReveNtioN soCiety
37 Return to contents
Qua
lity
re
quir
emen
tTh
resh
old
(rep
orti
ng
expe
ctat
ion)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(not
e w
here
spe
cifi
c gu
idan
ce is
not
pre
sent
this
is in
dica
ted
as ‘b
est
prac
tice
’)
Mon
itor
ing
Wh
ere
min
or
surg
ery
is
un
dert
aken
, su
rgic
al
site
infe
ctio
n
surv
eilla
nce
is
plan
ned
an
d re
por
ted
A s
urv
eilla
nce
pr
ogra
mm
e is
in
pla
ce t
o m
onit
or
surg
ical
in
terv
enti
ons
un
dert
aken
in
prim
ary
care
Evid
ence
an
d d
etai
l of
su
rvei
llan
ce
prog
ram
me,
de
fin
itio
ns
and
data
Perc
enta
ge o
f co
mpl
ian
ce
and
met
hod
of
mea
sure
men
t fo
r lo
cal
dete
rmin
atio
n a
nd
may
in
clu
de c
olla
bora
tion
w
ith
oth
er p
rovi
ders
.
Defi
nit
ion
of
surg
ical
pr
oced
ure
to
be d
efin
ed
loca
lly w
ith
co
mm
issi
oner
1B
est
prac
tice
Vacc
inat
ions
R
epor
tin
g on
co
mpl
ian
ce o
f h
ealt
h
care
wor
ker
vacc
inat
ion
pr
ogra
mm
e
An
nu
al c
onfi
rmat
ion
of
per
cen
tage
of
actu
al n
um
bers
an
d ty
pes
of
vacc
inat
ion
ag
ain
st e
ligib
le s
taff
An
nu
al r
epor
tin
g in
clu
din
g ex
cep
tion
s of
var
iati
on t
o p
olic
y
Vac
cin
atio
n is
re
com
men
ded
not
m
anda
ted
1A
lign
s w
ith
DH
(20
15)
Cod
e of
Pra
ctic
e cr
iter
ion
10
Pati
ents
iden
tifi
ed a
s el
igib
le fo
r va
ccin
atio
n s
tatu
s ar
e as
sess
ed a
nd
hav
e ou
tsta
ndi
ng
vacc
inat
ion
s of
fere
d by
pro
vide
r
Rep
orti
ng
of n
um
ber
of v
acci
nat
ion
s of
fere
d an
d ad
min
iste
red
Bi-
ann
ual
rep
orti
ng
Rep
orti
ng
to in
clu
de
brea
kdow
n p
er
vacc
inat
ion
cat
egor
y
1B
est
prac
tice
Inte
rnat
ion
al L
onge
vity
Cen
tre
(201
3) A
dult
vac
cina
tion
– a
ke
y co
mpo
nent
of h
ealt
hy a
gein
g w
ww
.ilcu
k.or
g.u
k/in
dex.
php/
publ
icat
ion
s/pu
blic
atio
n_d
etai
ls/a
dult
_vac
cin
atio
n_a
_ke
y_co
mp
onen
t_of
_hea
lthy
_age
ing
Pu
blic
Hea
lth
En
glan
d (2
014)
Im
mun
isat
ion
agai
nst
infe
ctio
us d
isea
se (
Gre
en b
ook)
ww
w.g
ov.u
k/go
vern
men
t/co
llect
ion
s/im
mu
nis
atio
n-a
gain
st-i
nfe
ctio
us-
dise
ase-
the-
gree
n-b
ook
3: In
fect
ion
prev
enti
on a
nd c
ontr
ol b
aske
t of s
ugge
sted
indi
cato
rs –
men
tal h
ealt
h
The
indi
cato
rs fo
r con
side
ratio
n be
low
refle
ct b
oth
NH
S pr
ovid
er in
-pat
ient
and
com
mun
ity se
rvic
e re
quir
emen
ts b
ased
on
patie
nt n
eed.
Qua
lity
requ
irem
ent
Thre
shol
d (r
epor
ting
ex
pect
atio
n)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(not
e w
here
spe
cifi
c gu
idan
ce is
not
pre
sent
this
is in
dica
ted
as ‘b
est
prac
tice
’)
Am
biti
on in
dica
tors
Th
e pr
ovid
er h
as in
pla
ce
a st
rate
gy t
hat
des
crib
es
its
visi
on a
nd
acti
ons
over
tim
e to
dia
gnos
e,
mea
sure
, pre
ven
t an
d m
anag
e al
l cas
es o
f pn
eum
onia
, in
clu
din
g bu
t n
ot li
mit
ed t
o th
ose
that
are
hea
lth
car
e ac
quir
ed
Evid
ence
of
stra
tegy
, in
clu
din
g h
ow it
will
be
rev
iew
ed a
nd
eval
uat
ed
Evid
ence
of
stra
tegy
an
d im
plem
enta
tion
p
lan
Stra
tegy
sh
ould
incl
ude
th
e ro
le o
f m
ult
i-di
scip
linar
y st
akeh
olde
rs
and
com
mu
nic
atio
n
path
way
s. S
trat
egy
may
be
dev
elop
ed a
nd
impl
emen
ted
in
colla
bora
tion
wit
h o
ther
pr
ovid
er o
rgan
isat
ion
s
1B
est
prac
tice
NIC
E C
G19
1 (2
014)
Pne
umon
ia: D
iagn
osis
and
m
anag
emen
t of c
omm
unit
y- a
nd h
ospi
tal-
acqu
ired
pn
eum
onia
in a
dult
s w
ww
.nic
e.or
g.u
k/gu
idan
ce/C
G19
1
Parl
iam
enta
ry a
nd
Hea
lth
Ser
vice
s O
mbu
dsm
an
(201
4) T
ime
to A
ct, s
ever
e se
psis
: rap
id d
iagn
osis
and
tr
eatm
ent s
aves
live
s w
ww
.om
buds
man
.org
.uk/
__d
ata/
asse
ts/p
df_fi
le/0
004/
2266
6/FI
NA
L_S
epsi
s_R
epor
t_w
eb.p
df
Th
e pr
ovid
er h
as in
pla
ce
a st
rate
gy t
hat
des
crib
es
its
visi
on a
nd
acti
ons
over
tim
e to
su
ppor
t pa
tien
ts in
th
e pr
even
tion
, dia
gnos
is
and
man
agem
ent
of
uri
nar
y tr
act
infe
ctio
ns,
in
clu
din
g th
ose
that
are
n
ot r
elat
ed t
o th
e u
se o
f u
rin
ary
cath
eter
s
Evid
ence
of
stra
tegy
, in
clu
din
g h
ow it
will
be
rev
iew
ed a
nd
eval
uat
ed
Evid
ence
of
stra
tegy
an
d im
plem
enta
tion
p
lan
Stra
tegy
sh
ould
incl
ude
th
e ro
le o
f m
ult
i-di
scip
linar
y st
akeh
olde
rs
and
com
mu
nic
atio
n
path
way
s.
Stra
tegy
may
be
deve
lop
ed a
nd
impl
emen
ted
in
colla
bora
tion
wit
h o
ther
pr
ovid
er o
rgan
isat
ion
s.
Not
e: m
ay a
lign
wit
h
prac
tice
indi
cato
rs o
n
falls
an
d C
AU
TI
(App
endi
x 3)
1B
est
prac
tice
NIC
E C
G54
(20
07)
Uri
nary
tra
ct in
fect
ion
in c
hild
ren:
D
iagn
osis
, tre
atm
ent a
nd lo
ng-t
erm
man
agem
ent
ww
w.n
ice.
org.
uk/
guid
ance
/cg5
4
NIC
E (
2014
) Q
ualit
y St
anda
rd I
nfec
tion
pre
vent
ion
and
cont
rol Q
S61
ww
w.n
ice.
org.
uk/
guid
ance
/qs6
1
NIC
E C
G 1
39 (
2012
) In
fect
ion:
Pre
vent
ion
and
cont
rol
of h
ealt
hcar
e-as
soci
ated
infe
ctio
ns in
pri
mar
y an
d co
mm
unit
y ca
re w
ww
.nic
e.or
g.u
k/gu
idan
ce/c
g139
Parl
iam
enta
ry a
nd
Hea
lth
Ser
vice
s O
mbu
dsm
an
(201
4) T
ime
to A
ct, s
ever
e se
psis
: rap
id d
iagn
osis
and
tr
eatm
ent s
aves
live
s w
ww
.om
buds
man
.org
.uk/
__d
ata/
asse
ts/p
df_fi
le/0
004/
2266
6/FI
NA
L_S
epsi
s_R
epor
t_w
eb.p
df
NIC
E (
2015
) Q
ualit
y St
anda
rd U
rina
ry t
ract
infe
ctio
ns
in a
dult
s Q
S90
ww
w.n
ice.
org.
uk/
guid
ance
/qs9
0
NIC
E (
2013
) Q
ualit
y St
anda
rd U
rina
ry t
ract
infe
ctio
n in
infa
nts,
chi
ldre
n an
d yo
ung
peop
le u
nder
16
QS3
6 w
ww
.nic
e.or
g.u
k/gu
idan
ce/q
s36
NIC
E g
uid
elin
es C
G16
1 (2
013)
Fal
ls: a
sses
smen
t an
d pr
even
tion
of f
alls
in o
lder
peo
ple
w
ww
.nic
e.or
g.u
k/gu
idan
ce/c
g161
This publication is being reviewed in 2019
38
InfectIon PreventIon and control commIssIonIng toolkIt
Return to contents
Qua
lity
requ
irem
ent
Thre
shol
d (r
epor
ting
ex
pect
atio
n)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(not
e w
here
spe
cifi
c gu
idan
ce is
not
pre
sent
this
is in
dica
ted
as ‘b
est
prac
tice
’)
Th
e pr
ovid
er h
as in
pla
ce
a st
rate
gy t
hat
des
crib
es
acti
ons
to r
ecog
nis
e m
easu
re a
nd
man
age
susp
ecte
d ca
ses
of s
epsi
s
Evid
ence
of
stra
tegy
, in
clu
din
g h
ow it
will
be
rev
iew
ed a
nd
eval
uat
ed
Evid
ence
of
stra
tegy
an
d im
plem
enta
tion
pl
an
Stra
tegy
sh
ould
incl
ude
th
e ro
le o
f m
ult
i-di
scip
linar
y st
akeh
olde
rs
and
com
mu
nic
atio
n
path
way
s.
Stra
tegy
may
be
deve
lop
ed a
nd
impl
emen
ted
in
colla
bora
tion
wit
h o
ther
pr
ovid
er o
rgan
isat
ion
s
1, 2
NH
S E
ngl
and
(201
5) C
omm
issi
onin
g fo
r qu
alit
y an
d in
nova
tion
(C
QU
IN)
Gui
danc
e fo
r 20
15/1
6
ww
w.e
ngl
and.
nh
s.u
k/w
p-co
nte
nt/
upl
oads
/201
5/03
/9-
cqu
in-g
uid
-201
5-16
Parl
iam
enta
ry a
nd
Hea
lth
Ser
vice
s O
mbu
dsm
an
(201
4) T
ime
to A
ct, s
ever
e se
psis
: rap
id d
iagn
osis
and
tr
eatm
ent s
aves
live
s w
ww
.om
buds
man
.org
.uk/
__d
ata/
asse
ts/p
df_fi
le/0
004/
2266
6/FI
NA
L_S
epsi
s_R
epor
t_w
eb.p
df
Org
anis
atio
nal e
lem
ents
IPC
is in
clu
ded
as a
re
gula
r ag
enda
item
in
prov
ider
org
anis
atio
n
mee
tin
gs
Rec
ord
of m
eeti
ngs
an
d IP
C t
opic
s di
scu
ssed
Min
ute
s of
m
eeti
ngs
Pro
vide
r to
det
erm
ine
wh
ich
mee
tin
gs w
ill
rou
tin
ely
incl
ude
IP
C
disc
uss
ion
1B
est
prac
tice
NIC
E (
2014
) Q
ualit
y St
anda
rd I
nfec
tion
pre
vent
ion
and
Con
trol
QS6
1 w
ww
.nic
e.or
g.u
k/gu
idan
ce/q
s61
Th
e or
gan
isat
ion
de
velo
ps a
nd
own
s a
boar
d-ap
prov
ed H
CA
I re
duct
ion
pla
n a
nd
prog
ress
is r
epor
ted
ag
ain
st t
his
Qu
arte
rly
com
plia
nce
rep
orts
Qu
arte
rly
rece
ipt
of r
epor
ts d
etai
ling
com
plia
nce
an
d pr
ogre
ss a
gain
st
pla
n
Th
e pr
ovid
er m
ay w
ish
to
use
th
e C
ode
of P
ract
ice
to
deve
lop
an I
PC
pla
n
1N
HS
En
glan
d St
anda
rd C
ontr
act
ww
w.e
ngl
and.
nh
s.u
k/n
hs-
stan
dard
-con
trac
t/15
-16/
NH
S E
ngl
and
Stan
dard
Con
trac
t 201
5/16
and
201
6/17
w
ww
.en
glan
d.n
hs.
uk/
nh
s-st
anda
rd-c
ontr
act/
15-1
6/
ww
w.e
ngl
and.
nh
s.u
k/n
hs-
stan
dard
-con
trac
t/16
-17/
An
tim
icro
bial
st
ewar
dsh
ip (
AM
S) is
in
clu
ded
as a
reg
ula
r ag
enda
item
in p
rovi
der
orga
nis
atio
n m
eeti
ngs
Rec
ord
of m
eeti
ngs
an
d A
MS
top
ics
disc
uss
ed
Min
ute
s of
m
eeti
ngs
Pro
vide
r to
det
erm
ine
wh
ich
mee
tin
gs w
ill
rou
tin
ely
incl
ude
AM
S di
scu
ssio
n
2B
est
prac
tice
NIC
E G
uid
elin
e N
G15
(20
15)
Ant
imic
robi
al
stew
ards
hip:
sys
tem
s an
d pr
oces
ses
for
effe
ctiv
e an
tim
icro
bial
med
icin
e us
e w
ww
.nic
e.or
g.u
k/gu
idan
ce/
NG
15/c
hap
ter/
2-Im
plem
enta
tion
-get
tin
g-st
arte
d
NIC
E (
2014
) Q
ualit
y St
anda
rd I
nfec
tion
pre
vent
ion
and
cont
rol Q
S61
ww
w.n
ice.
org.
uk/
guid
ance
/qs6
1 P
rovi
der
take
s in
to
acco
un
t ad
vice
from
sp
ecia
list
IP
C a
nd
AM
S pr
ovid
er/t
eam
s
Doc
um
enta
tion
an
d de
tails
of
deci
sion
/re
med
ial a
ctio
n
Rec
ords
of
deci
sion
in
min
ute
s/ot
her
do
cum
enta
tion
Wh
ere
spec
ialis
t IP
C/
AM
S ad
vice
is n
ot
follo
wed
, th
e ra
tion
ale
and
deci
sion
is
docu
men
ted
and
disc
uss
ed a
t th
e re
leva
nt
mee
tin
g (s
ee t
wo
indi
cato
rs a
bove
)
1, 2
Bes
t pr
acti
ce
NIC
E G
uid
elin
e N
G15
(20
15)
Ant
imic
robi
al
stew
ards
hip:
sys
tem
s an
d pr
oces
ses
for
effe
ctiv
e an
tim
icro
bial
med
icin
e us
e w
ww
.nic
e.or
g.u
k/gu
idan
ce/
NG
15/c
hap
ter/
2-Im
plem
enta
tion
-get
tin
g-st
arte
d
This publication is being reviewed in 2019
Royal College of NuRsiNg aNd iNfeCtioN PReveNtioN soCiety
39 Return to contents
Qua
lity
requ
irem
ent
Thre
shol
d (r
epor
ting
ex
pect
atio
n)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(not
e w
here
spe
cifi
c gu
idan
ce is
not
pre
sent
this
is in
dica
ted
as ‘b
est
prac
tice
’)
Th
e or
gan
isat
ion
em
ploy
s or
has
su
ffici
ent
acce
ss t
o a
suit
ably
re
sou
rced
an
d qu
alifi
ed
Infe
ctio
n P
reve
nti
on a
nd
C
ontr
ol T
eam
(IP
CT
),
An
tim
icro
bial
St
ewar
dsh
ip (
AM
S) t
eam
or
sp
ecia
list
prac
titi
oner
to
mee
t th
eir
nee
ds
Spec
ialis
t ad
vise
rs
are
clea
rly
iden
tifi
able
Rec
ord
of s
ervi
ce
or c
ontr
act
for
prov
isio
n o
f IP
C
and
AM
S ad
vice
Con
trac
t m
ay b
e fo
r em
ploy
men
t or
adv
ice
and
shou
ld d
etai
l th
e n
um
ber
of h
ours
em
ploy
ed/c
ontr
acte
d,
role
des
crip
tion
, lin
es o
f co
mm
un
icat
ion
an
d go
vern
ance
str
uct
ure
s fo
r IP
C a
nd
wit
hin
pro
vide
r or
gan
isat
ion
1B
est
prac
tice
NIC
E (
2014
) Q
ualit
y St
anda
rd Q
S61
ww
w.n
ice.
org.
uk/
guid
ance
/QS6
1/ch
apte
r/L
ist-
of-q
ual
ity-
stat
emen
ts
NIC
E G
uid
elin
e N
G15
(20
15)
Ant
imic
robi
al
stew
ards
hip:
sys
tem
s an
d pr
oces
ses
for
effe
ctiv
e an
tim
icro
bial
med
icin
e us
e w
ww
.nic
e.or
g.u
k/gu
idan
ce/
NG
15/c
hap
ter/
2-Im
plem
enta
tion
-get
tin
g-st
arte
d
Pro
vide
r co
ntr
ibu
tes
to
wh
ole
econ
omy
stra
tegi
c pl
ann
ing
disc
uss
ion
an
d de
cisi
on m
akin
g on
H
CA
I re
duct
ion
Rec
ord
of
atte
nda
nce
an
d co
ntr
ibu
tion
Min
ute
s of
m
eeti
ngs
Loca
l HC
AI
prov
ider
or
prof
essi
onal
net
wor
ks
can
be
use
d as
a m
eth
od
of d
emon
stra
tin
g en
gage
men
t in
dis
cuss
ion
an
d pl
ann
ing
1B
est
prac
tice
NIC
E (
2014
) Q
ualit
y St
anda
rd Q
S61
w
ww
.nic
e.or
g.u
k/gu
idan
ce/q
s61
NIC
E G
uid
elin
e N
G15
(20
15)
Ant
imic
robi
al
stew
ards
hip:
sys
tem
s an
d pr
oces
ses
for
effe
ctiv
e an
tim
icro
bial
med
icin
e us
e w
ww
.nic
e.or
g.u
k/gu
idan
ce/
NG
15/c
hap
ter/
2-Im
plem
enta
tion
-get
tin
g-st
arte
d
Cop
ies
of a
ll re
por
ts a
nd
asso
ciat
ed a
ctio
n p
lan
s in
re
spon
se t
o an
y ex
tern
al
IPC
focu
s vi
sits
/in
spec
tion
s (e
.g. f
rom
D
H, C
CG
, CQ
C, T
DA
, M
onit
or)
are
mad
e av
aila
ble
to t
he
com
mis
sion
er b
y th
e pr
ovid
er
Cop
ies
of r
epor
ts
sen
t to
co
mm
issi
oner
w
ith
in fi
ve w
orki
ng
days
of
the
prov
ider
re
ceiv
ing
the
rep
ort
Rep
orts
are
re
ceiv
ed1
Bes
t pr
acti
ce
Ser
vice
use
r in
volv
emen
tSe
rvic
e u
sers
are
in
clu
ded
in I
PC
an
nu
al
prog
ram
me
de
velo
pmen
t, w
ith
pa
tien
t ex
per
ien
ce u
sed
to s
hap
e ac
tivi
ty
Serv
ice
use
r vi
ews
are
acti
vely
sou
ght
and
reco
mm
enda
tion
s in
corp
orat
ed w
her
e ap
prop
riat
e
Evid
ence
an
d de
tail
of p
arti
cipa
tion
in
ann
ual
rep
ort
1,3
Bes
t pr
acti
ce
This publication is being reviewed in 2019
40
InfectIon PreventIon and control commIssIonIng toolkIt
Return to contents
Qua
lity
requ
irem
ent
Thre
shol
d (r
epor
ting
ex
pect
atio
n)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(not
e w
here
spe
cifi
c gu
idan
ce is
not
pre
sent
this
is in
dica
ted
as ‘b
est
prac
tice
’)
Serv
ice
use
rs a
re in
volv
ed
in t
he
shap
ing
and
impl
emen
tati
on o
f lo
cal
prog
ram
mes
to
impr
ove
han
d hy
gien
e of
bot
h
staf
f an
d se
rvic
e u
sers
in
all s
etti
ngs
Serv
ice
use
rs a
re
invo
lved
in h
and
hygi
ene
prog
ram
mes
An
nu
al s
um
mar
y of
han
d hy
gien
e pr
ogra
mm
e ac
tivi
ty, i
ncl
udi
ng
use
r in
volv
emen
t
1,3
NIC
E (
2014
) Q
ualit
y St
anda
rd Q
S61
w
ww
.nic
e.or
g.u
k/gu
idan
ce/q
s61
NIC
E C
G 1
39 (
2012
) In
fect
ion:
Pre
vent
ion
and
cont
rol
of h
ealt
hcar
e-as
soci
ated
infe
ctio
ns in
pri
mar
y an
d co
mm
unit
y ca
re w
ww
.nic
e.or
g.u
k/gu
idan
ce/c
g139
Pati
ents
wit
h in
vasi
ve
devi
ces
such
as
a u
rin
ary
cath
eter
, vas
cula
r ac
cess
de
vice
or
ente
ral f
eedi
ng
tube
, as
wel
l as
thei
r ca
rers
, are
giv
en
info
rmat
ion
an
d ad
vice
ab
out
how
to
look
aft
er
the
equ
ipm
ent
safe
ly a
nd
effe
ctiv
ely
Serv
ice
use
rs a
re
prov
ided
wit
h
advi
ce a
nd
are
invo
lved
in
dete
rmin
ing
deta
il of
info
rmat
ion
in
clu
ded
An
nu
al s
um
mar
y of
info
rmat
ion
av
aila
ble,
d
istr
ibu
tion
an
d ev
alu
atio
n
incl
udi
ng
pat
ien
t/ca
rer
feed
back
1,3
NIC
E (
2014
) Q
ualit
y St
anda
rd Q
S61
w
ww
.nic
e.or
g.u
k/gu
idan
ce/q
s61
NIC
E C
G 1
39 (
2012
) In
fect
ion:
Pre
vent
ion
and
cont
rol
of h
ealt
hcar
e-as
soci
ated
infe
ctio
ns in
pri
mar
y an
d co
mm
unit
y ca
re w
ww
.nic
e.or
g.u
k/gu
idan
ce/c
g139
MR
SA
, C. d
iffi
cile
and
oth
er s
igni
fica
nt H
CA
IsT
he
prov
ider
con
trib
ute
s to
th
e Po
st I
nfe
ctio
n
Rev
iew
/ R
CA
/‘L
apse
in
care
’ inv
esti
gati
ons
for
all
case
s of
HC
AI
Con
trib
uti
on t
o th
e P
IR p
roce
ss a
nd
impl
emen
tati
on o
f ac
tion
pla
ns
and
lear
nin
g de
rive
d fr
om in
vest
igat
ion
re
view
s.
100%
att
enda
nce
at
inve
stig
atio
n
mee
tin
gs
Att
end
ance
at
PIR
m
eeti
ngs
.
Act
ion
pla
n r
epor
ts
are
rece
ived
an
d
upd
ated
reg
ula
rly,
w
ith
lear
nin
g sh
ared
acr
oss
the
orga
nis
atio
n
Wit
h e
xcep
tion
s of
M
RSA
bac
tera
emia
an
d C
. dif
ficile
infe
ctio
n,
oth
er H
CA
Is t
hat
req
uir
e in
vest
igat
ion
are
to
be
dete
rmin
ed lo
cally
1, 2
, 5N
HS
En
glan
d (2
014)
Zer
o to
lera
nce
ww
w.e
ngl
and
.nh
s.u
k/pa
tien
tsaf
ety/
asso
ciat
ed-i
nfe
ctio
ns/
zero
-tol
eran
ce/
NH
S E
ngl
and
(201
5) C
lost
ridi
um
dif
fici
le in
fect
ion
obje
ctiv
es fo
r N
HS
orga
nisa
tion
s in
201
5/16
and
gu
idan
ce o
n sa
ncti
on im
plem
enta
tion
ww
w.e
ngl
and
.nh
s.u
k/w
p-co
nte
nt/
upl
oads
/201
5/02
/clo
stri
dm-d
iffi
cile
-in
fect
-obj
ct-1
5-16
-gu
id-f
eb15
This publication is being reviewed in 2019
Royal College of NuRsiNg aNd iNfeCtioN PReveNtioN soCiety
41 Return to contents
Qua
lity
requ
irem
ent
Thre
shol
d (r
epor
ting
ex
pect
atio
n)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(not
e w
here
spe
cifi
c gu
idan
ce is
not
pre
sent
this
is in
dica
ted
as ‘b
est
prac
tice
’)
Com
plia
nce
wit
h lo
cally
ag
reed
MR
SA c
are
path
way
Qu
arte
rly
con
firm
atio
n o
f p
erce
nta
ge o
f M
RSA
-pos
itiv
e pa
tien
ts w
ho
follo
w
and
com
plet
e th
e M
RSA
car
e pa
thw
ay
Qu
arte
rly
rece
ipt
of M
RSA
car
e pa
thw
ay
com
plia
nce
dat
a
Car
e pa
thw
ays
shou
ld b
e de
fin
ed lo
cally
an
d al
l pr
ovid
ers
shou
ld b
e aw
are
of t
hes
e an
d co
mpl
y w
ith
th
em.
Con
side
r in
clu
sion
of
audi
t of
flag
gin
g of
M
RSA
sta
tus
acro
ss a
ll pa
tien
t ad
min
istr
atio
n
syst
ems
acro
ss t
he
path
way
.
Perc
enta
ge o
f co
mpl
ian
ce
and
met
hod
of
mea
sure
men
t fo
r lo
cal
dete
rmin
atio
n
1N
HS
En
glan
d (2
014)
Zer
o to
lera
nce
ww
w.e
ngl
and
.nh
s.u
k/pa
tien
tsaf
ety/
asso
ciat
ed-i
nfe
ctio
ns/
zero
-tol
eran
ce/
Pati
ents
wh
o m
eet
the
crit
eria
for
MR
SA
scre
enin
g ar
e m
anag
ed a
s p
er lo
cally
agr
eed
prot
ocol
s an
d al
l pos
itiv
e re
sult
s ar
e ac
ted
up
on
Mon
thly
co
nfi
rmat
ion
of
per
cen
tage
of
elig
ible
cas
es
scre
ened
for
MR
SA
Mon
thly
rec
eip
t of
sc
reen
ing
data
D
etai
l of
mea
sure
men
t m
eth
od t
o be
det
erm
ined
lo
cally
, e.g
. pro
toco
l for
el
igib
ility
.
100%
com
plia
nce
is fo
r lo
cal d
eter
min
atio
n
1,5
NH
S E
ngl
and
(201
4) Z
ero
tole
ranc
e w
ww
.en
glan
d.n
hs.
uk/
pati
ents
afet
y/as
soci
ated
-in
fect
ion
s/ze
ro-t
oler
ance
/
DH
(20
14)
Impl
emen
tati
on o
f mod
ified
adm
issi
on
MR
SA s
cree
ning
gui
danc
e fo
r N
HS
(201
4) w
ww
.gov
.uk/
gove
rnm
ent/
upl
oads
/sys
tem
/upl
oads
/att
ach
men
t_da
ta/fi
le/3
4514
4/Im
plem
enta
tion
_of_
mod
ified
_ad
mis
sion
_MR
SA_s
cree
nin
g_gu
idan
ce_f
or_N
HS.
pd
f
Com
plia
nce
wit
h lo
cally
ag
reed
C. d
iffic
ile c
are
path
way
Qu
arte
rly
con
firm
atio
n o
f p
erce
nta
ge o
f C
. di
ffici
le p
atie
nts
wh
o fo
llow
an
d co
mpl
ete
the
care
pat
hway
Qu
arte
rly
rece
ipt
of C
. dif
ficile
car
e p
athw
ay
com
plia
nce
dat
a
Car
e pa
thw
ays
shou
ld b
e de
fin
ed lo
cally
an
d al
l pr
ovid
ers
shou
ld b
e aw
are
of t
hem
an
d co
ntr
ibu
te w
her
e re
leva
nt.
Con
side
r in
clu
sion
of
audi
t of
fl
aggi
ng
of C
. dif
ficile
st
atu
s ac
ross
all
pati
ent
adm
inis
trat
ion
sys
tem
s ac
ross
th
e pa
thw
ay.
Perc
enta
ge o
f co
mpl
ian
ce
and
met
hod
of
mea
sure
men
t fo
r lo
cal
dete
rmin
atio
n
1B
est
prac
tice
This publication is being reviewed in 2019
42
InfectIon PreventIon and control commIssIonIng toolkIt
Return to contents
Qua
lity
requ
irem
ent
Thre
shol
d (r
epor
ting
ex
pect
atio
n)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(not
e w
here
spe
cifi
c gu
idan
ce is
not
pre
sent
this
is in
dica
ted
as ‘b
est
prac
tice
’)
Pro
vide
r co
ntr
ibu
tes
to
revi
ew o
f al
l C. d
iffic
ile
infe
ctio
n (
CD
I) c
ases
if
invo
lved
in p
rovi
sion
of
care
to
pati
ent
100%
com
plia
nce
w
ith
invo
lvem
ent
in
revi
ew o
f an
y C
DI
case
th
at t
he
prov
ider
is
asso
ciat
ed w
ith
Qu
arte
rly
subm
issi
on o
f ev
iden
ce
dem
onst
rati
ng
prov
ider
in
volv
emen
t in
re
view
mee
tin
gs
and
prog
ress
wit
h
acti
ons
Det
ail o
f m
easu
rem
ent
met
hod
to
be d
eter
min
ed
loca
lly
1N
HS
En
glan
d (2
015)
Clo
stri
diu
m d
iffi
cile
infe
ctio
n ob
ject
ives
for
NH
S or
gani
sati
ons
in 2
015/
16 a
nd
guid
ance
on
sanc
tion
impl
emen
tati
on a
t w
ww
.en
glan
d.
nh
s.u
k/w
p-co
nte
nt/
upl
oads
/201
5/02
/clo
stri
dm-
diffi
cile
-in
fect
-obj
ct-1
5-16
-gu
id-f
eb15
All
susp
ecte
d in
fect
ion
s an
d co
nfi
rmed
ou
tbre
aks
are
rep
orte
d to
th
e co
mm
issi
oner
an
d lo
cal
hea
lth
pro
tect
ion
tea
m
wit
hou
t de
lay
All
con
firm
ed o
r ou
tbre
aks
are
rep
orte
d by
th
e n
ext
wor
kin
g d
ay
Mon
thly
rep
orti
ng
1,5
Car
e Q
ual
ity
Com
mis
sion
web
site
ww
w.c
qc.o
rg.u
k/co
nte
nt/
not
ifica
tion
s-n
on-n
hs-
tru
st-p
rovi
ders
Seri
ous
inci
den
ts a
re
rep
orte
d to
th
e co
mm
issi
oner
wit
hin
on
e w
orki
ng
day
Not
ifica
tion
of
inci
den
t to
co
mm
issi
oner
w
ith
in t
wo
wor
kin
g da
ys
Qu
arte
rly
rep
orti
ng
Defi
nit
ion
of
seri
ous
inci
den
t to
be
defi
ned
by
prov
ider
follo
win
g ag
reem
ent
wit
h
com
mis
sion
er.
Ver
ifica
tion
mea
sure
–
STE
IS, N
RL
S, R
CA
, P
IR, p
atie
nt
com
plai
nts
1H
PA (
2012
) H
ealt
hcar
e as
soci
ated
infe
ctio
n op
erat
iona
l gu
idan
ce a
nd s
tand
ards
for
heal
th p
rote
ctio
n un
its
w
ww
.gov
.uk/
gove
rnm
ent/
publ
icat
ion
s/h
ealt
hca
re-
asso
ciat
ed-i
nfe
ctio
n-h
cai-
oper
atio
nal
-gu
idan
ce-a
nd
-st
anda
rds
NH
S E
ngl
and
(201
5) S
erio
us in
cide
nt fr
amew
ork
w
ww
.en
glan
d.n
hs.
uk/
pati
ents
afet
y/se
riou
s-in
cide
nt/
Th
e pr
ovid
er h
as a
sy
stem
in p
lace
to
supp
ort
prep
ared
nes
s or
m
anag
emen
t of
pat
ien
ts
carr
yin
g ca
rbap
enae
mas
e-pr
odu
cin
g E
nte
roba
cter
iace
ae
(CP
E)
in li
ne
wit
h P
HE
C
PE
gu
idan
ce
Th
e pr
ovid
er h
as a
p
olic
y in
pla
ce fo
r th
e m
anag
emen
t of
C
PE
an
d h
as
con
side
red
the
impl
icat
ion
s of
its
impl
emen
tati
on o
n
its
serv
ice
Con
firm
atio
n o
f p
olic
y in
pla
ce1
PH
E (
2015
) To
olki
t for
man
agin
g ca
rbap
enem
ase-
prod
ucin
g En
tero
bact
eria
ceae
in n
on-a
cute
and
co
mm
unit
y se
ttin
gs w
ww
.gov
.uk/
gove
rnm
ent/
up
load
s/sy
stem
/upl
oads
/att
ach
men
t_da
ta/fi
le/4
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1/C
PE
-N
on-A
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Tool
kit_
CO
RE
IPC
prac
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Th
e or
gan
isat
ion
has
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IP
C l
ink
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titi
oner
pr
ogra
mm
e in
pla
ce
Syst
em is
in p
lace
an
d fu
nct
ion
ing
Bi-
ann
ual
re
por
tin
g of
lin
k pr
acti
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er
acti
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1B
est
prac
tice
RC
N (
2011
) R
CN
link
nur
se fr
amew
ork
ww
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.org
.uk/
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15/0
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f This publication is being reviewed in 2019
Royal College of NuRsiNg aNd iNfeCtioN PReveNtioN soCiety
43 Return to contents
Qua
lity
requ
irem
ent
Thre
shol
d (r
epor
ting
ex
pect
atio
n)
Met
hod
of
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ence
/su
ppor
ting
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rce
(not
e w
here
spe
cifi
c gu
idan
ce is
not
pre
sent
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is in
dica
ted
as ‘b
est
prac
tice
’)
A lo
cal s
urv
eilla
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pr
ogra
mm
e is
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lace
to
refl
ect
loca
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risk
ass
essm
ent
Loca
l su
rvei
llan
ce
prog
ram
me
is in
pl
ace
and
im
plem
ente
d
Cop
y of
su
rvei
llan
ce
prog
ram
me
and
outc
omes
Perc
enta
ge o
f co
mpl
ian
ce
and
met
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mea
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men
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rmin
atio
n
1,5
Bes
t pr
acti
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Th
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ovid
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as in
pla
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rate
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syst
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to
ensu
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he
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of
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oces
ses
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se
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sion
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thly
re
por
tin
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ogre
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ateg
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emen
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re fo
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eter
min
atio
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opu
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, bu
t ca
n
incl
ude
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men
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ppen
dix
5
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,5B
est
prac
tice
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E (
2014
) Q
ualit
y St
anda
rd Q
S61
w
ww
.nic
e.or
g.u
k/gu
idan
ce/q
s61
NIC
E C
G 1
39 (
2012
) In
fect
ion:
Pre
vent
ion
and
cont
rol
of h
ealt
hcar
e-as
soci
ated
infe
ctio
ns in
pri
mar
y an
d co
mm
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re w
ww
.nic
e.or
g.u
k/gu
idan
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ctio
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ith
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se o
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ther
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ence
of
stra
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an
d p
roce
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se
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s dr
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id
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aren
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l n
utr
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uir
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re fo
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eter
min
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n
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ude
ele
men
ts
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ude
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E (
2014
) Q
ualit
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rd Q
S61
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ww
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rate
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to
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ctio
ns
asso
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ith
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se o
f en
tera
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of
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tegy
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d p
roce
sses
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se
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mis
sion
er
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mon
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re
por
tin
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ogre
ss in
str
ateg
y
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uir
emen
ts a
re fo
r lo
cal d
eter
min
atio
n
base
d on
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ien
t p
opu
lati
on a
nd
serv
ice
spec
ifica
tion
, bu
t ca
n
incl
ude
ele
men
ts in
A
ppen
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5
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t pr
acti
ce
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E C
G 1
39 (
2012
) In
fect
ion:
Pre
vent
ion
and
cont
rol
of h
ealt
hcar
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ated
infe
ctio
ns in
pri
mar
y an
d co
mm
unit
y ca
re w
ww
.nic
e.or
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k/gu
idan
ce/c
g139
All
staf
f h
ave
acce
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o re
sou
rces
to
supp
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gien
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th
e p
oin
t of
car
e w
hen
indi
cate
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Evid
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rces
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se
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rovi
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and
use
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pra
ctic
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Six-
mon
thly
rev
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an
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alu
atio
n o
f pr
odu
ct u
se
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uir
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re fo
r lo
cal d
eter
min
atio
n
base
d on
pat
ien
t p
opu
lati
on a
nd
serv
ice
sett
ing
1N
ICE
(20
14)
Qua
lity
Stan
dard
QS6
1
ww
w.n
ice.
org.
uk/
guid
ance
/qs6
1
NIC
E C
G 1
39 (
2012
) In
fect
ion:
Pre
vent
ion
and
cont
rol
of h
ealt
hcar
e-as
soci
ated
infe
ctio
ns in
pri
mar
y an
d co
mm
unit
y ca
re w
ww
.nic
e.or
g.u
k/gu
idan
ce/c
g139
This publication is being reviewed in 2019
44
InfectIon PreventIon and control commIssIonIng toolkIt
Return to contents
Qua
lity
requ
irem
ent
Thre
shol
d (r
epor
ting
ex
pect
atio
n)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(not
e w
here
spe
cifi
c gu
idan
ce is
not
pre
sent
this
is in
dica
ted
as ‘b
est
prac
tice
’)
Loca
lly d
eter
min
ed I
PC
tr
ain
ing
prog
ram
me
is
deliv
ered
as
per
loca
lly
agre
ed p
lan
for
each
sta
ff
grou
p
Bi-
ann
ual
rep
orts
an
d ev
alu
atio
n o
f tr
ain
ing
prog
ram
me
is r
ecei
ved
Bi-
ann
ual
re
por
tin
gPe
rcen
tage
of
com
plia
nce
an
d m
eth
od o
f m
easu
rem
ent
for
loca
l de
term
inat
ion
1,3
Alig
ns
wit
h D
H (
2015
) C
ode
of p
ract
ice
Pres
crib
ing
Th
e pr
ovid
er h
as o
r co
ntr
ibu
tes
to a
n
anti
biot
ic s
tew
ards
hip
pr
ogra
mm
e th
at s
pan
s ca
re s
etti
ngs
loca
lly
Evid
ence
of
atte
nda
nce
at
rele
van
t m
eeti
ngs
an
d co
ntr
ibu
tion
to
loca
l AM
S pr
ogra
mm
e
Rep
orti
ng
of
prog
ress
wit
h A
MS
prog
ram
me
Perc
enta
ge o
f co
mpl
ian
ce, m
eth
od o
f m
easu
rem
ent,
incl
usi
on
crit
eria
an
d fr
equ
ency
of
com
plia
nce
ass
essm
ent
for
loca
l det
erm
inat
ion
2,3
Bes
t pr
acti
ce
NIC
E G
uid
elin
e N
G15
(20
15)
Ant
imic
robi
al
stew
ards
hip:
sys
tem
s an
d pr
oces
ses
for
effe
ctiv
e an
tim
icro
bial
med
icin
e us
e w
ww
.nic
e.or
g.u
k/gu
idan
ce/
NG
15/c
hap
ter/
2-Im
plem
enta
tion
-get
tin
g-st
arte
d
An
an
tibi
otic
pol
icy
is in
pl
ace
that
refl
ects
n
atio
nal
pre
scri
bin
g gu
idan
ce
Pre
sen
ce o
f an
tibi
otic
pol
icy
An
nu
al
con
firm
atio
n o
f p
olic
y in
pla
ce
Polic
y sh
ould
be
revi
ewed
min
imu
m o
f tw
o-ye
arly
un
less
new
n
atio
nal
gu
idan
ce is
sued
2N
ICE
Gu
idel
ine
NG
15 (
2015
) A
ntim
icro
bial
st
ewar
dshi
p: s
yste
ms
and
proc
esse
s fo
r ef
fect
ive
anti
mic
robi
al m
edic
ine
use
ww
w.n
ice.
org.
uk/
guid
ance
/N
G15
/ch
apte
r/2-
Impl
emen
tati
on-g
etti
ng-
star
ted
Com
plia
nce
wit
h lo
cal
anti
biot
ic p
olic
ies
Rep
orti
ng
of
com
plia
nce
in
clu
din
g if
th
ere
is
evid
ence
of
just
ifiab
le c
linic
al
reas
ons
for
devi
atio
n fr
om s
et
form
ula
ry
Au
dit
of
com
plia
nce
, wit
h
the
anti
biot
ic
pres
crib
ing
form
ula
ry
Perc
enta
ge o
f co
mpl
ian
ce, m
eth
od o
f m
easu
rem
ent,
incl
usi
on
crit
eria
an
d fr
equ
ency
of
com
plia
nce
ass
essm
ent
for
loca
l det
erm
inat
ion
2N
ICE
(20
14)
Qua
lity
Stan
dard
QS6
1
ww
w.n
ice.
org.
uk/
guid
ance
/qs6
1
NIC
E G
uid
elin
e N
G15
(20
15)
Ant
imic
robi
al
stew
ards
hip:
sys
tem
s an
d pr
oces
ses
for
effe
ctiv
e an
tim
icro
bial
med
icin
e us
e w
ww
.nic
e.or
g.u
k/gu
idan
ce/
NG
15/c
hap
ter/
2-Im
plem
enta
tion
-get
tin
g-st
arte
d
Pre
scri
bers
mee
t th
eir
prof
essi
onal
sta
nda
rds
of
edu
cati
on a
nd
com
pet
ency
An
nu
al r
epor
t of
tr
ain
ing
and
co
mp
eten
cy
An
nu
al r
epor
t an
d an
alys
is a
gain
st
qual
ity
requ
irem
ent
Info
rmat
ion
sh
ould
be
prov
ided
on
th
e n
um
bers
of
dif
fere
nt
prof
essi
onal
gr
oups
rec
eivi
ng
trai
nin
g an
d co
mp
eten
cy
asse
ssm
ent
com
pare
d to
th
ose
that
are
elig
ible
2,3
Pu
blic
Hea
lth
En
glan
d (2
013)
Ant
imic
robi
al p
resc
ribi
ng
and
stew
ards
hip
com
pete
ncie
s w
ww
.gov
.uk/
gove
rnm
ent/
upl
oads
/sys
tem
/upl
oads
/att
ach
men
t_da
ta/fi
le/2
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RH
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pet
enci
es__
2_.p
df
This publication is being reviewed in 2019
Royal College of NuRsiNg aNd iNfeCtioN PReveNtioN soCiety
45 Return to contents
Qua
lity
requ
irem
ent
Thre
shol
d (r
epor
ting
ex
pect
atio
n)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(not
e w
here
spe
cifi
c gu
idan
ce is
not
pre
sent
this
is in
dica
ted
as ‘b
est
prac
tice
’)
Hea
lth
car
e pr
ofes
sion
als
rece
ive
edu
cati
on a
s pa
rt
of t
he
prov
ider
s’ o
ngo
ing
trai
nin
g re
spon
sibi
lity
on
anti
mic
robi
al r
esis
tan
ce,
incl
udi
ng
best
pra
ctic
e in
m
edic
ines
op
tim
isat
ion
An
nu
al r
epor
t of
tr
ain
ing
nu
mbe
rs
and
per
cen
tage
of
thos
e w
ho
hav
e co
mpl
eted
tra
inin
g
Evid
ence
an
d de
tail
of p
arti
cipa
tion
in
ann
ual
sta
tem
ent
Edu
cati
on s
hou
ld fo
cus
on a
n h
olis
tic
appr
oach
to
an
tim
icro
bial
age
nts
, in
clu
din
g th
erap
euti
c m
anag
emen
t, pr
escr
ibin
g an
d di
spen
sin
g ad
vice
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pati
ents
2,3
Bes
t pr
acti
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NIC
E G
uid
elin
e N
G15
(20
15)
Ant
imic
robi
al
stew
ards
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sys
tem
s an
d pr
oces
ses
for
effe
ctiv
e an
tim
icro
bial
med
icin
e us
e w
ww
.nic
e.or
g.u
k/gu
idan
ce/
NG
15/c
hap
ter/
2-Im
plem
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DH
(20
13)
UK
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yea
r an
tim
icro
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ista
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stra
tegy
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Hea
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ngl
and
(201
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reve
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Hea
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htt
ps:/
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k/ou
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ork/
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Th
e or
gan
isat
ion
pa
rtic
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es a
nn
ual
ly in
aw
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ess-
rais
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prog
ram
mes
th
at
supp
ort
best
pra
ctic
e in
an
tim
icro
bial
pr
escr
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se, e
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Eu
rop
ean
An
tibi
otic
A
war
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ay (
EA
AD
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orld
An
tibi
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war
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eek
(WA
AW
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Incl
usi
on in
an
nu
al
IPC
rep
ort
Evid
ence
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tail
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arti
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an
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epor
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Typ
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act
ivit
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r lo
cal
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rmin
atio
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Bes
t pr
acti
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EC
DC
web
site
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ttp:
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/hom
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Th
e pr
ovid
er h
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pla
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a pl
an t
o ac
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re
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mbe
r of
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tibi
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Th
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5/16
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idan
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ww
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ual
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6.pd
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This publication is being reviewed in 2019
46
InfectIon PreventIon and control commIssIonIng toolkIt
Return to contents
Qua
lity
requ
irem
ent
Thre
shol
d (r
epor
ting
ex
pect
atio
n)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(not
e w
here
spe
cifi
c gu
idan
ce is
not
pre
sent
this
is in
dica
ted
as ‘b
est
prac
tice
’)
Th
e pr
ovid
er h
as in
pla
ce
a pl
an t
o ac
hie
ve a
re
duct
ion
in t
he
prop
orti
on o
f br
oad-
spec
tru
m a
nti
biot
ics
pres
crib
ed
Th
e pr
ovid
er c
an
dem
onst
rate
th
at
the
nu
mbe
r of
ce
phal
osp
orin
s,
quin
olon
es a
nd
co-a
mox
icla
v as
a
per
cen
tage
of
the
tota
l nu
mbe
r of
an
tibi
otic
s pr
escr
ibed
is
redu
ced
by 1
0% o
r be
low
th
e cu
rren
t m
edia
n p
rop
orti
on
for
En
glis
h C
CG
s (w
hic
hev
er is
met
fi
rst)
As
per
Qu
alit
y P
rem
ium
det
ail
2N
HS
En
glan
d (2
015)
Qua
lity
Pre
miu
m: 2
015/
16
guid
ance
for
CC
Gs
ww
w.e
ngl
and.
nh
s.u
k/w
p-co
nte
nt/
upl
oads
/201
5/04
/qu
al-p
rem
-gu
id-1
516.
Phy
sica
l hea
lth
Org
anis
atio
n h
as in
pla
ce
a m
ult
i-di
scip
linar
y tr
ain
ing
and
com
pet
ency
as
sess
men
t fo
r th
e ca
re o
f pa
tien
ts w
ith
phy
sica
l h
ealt
h n
eeds
to
supp
ort
wel
lbei
ng
and
the
prev
enti
on o
f in
fect
ion
Trai
nin
g an
d co
mp
eten
cy
prog
ram
me
is in
pl
ace
Bi-
ann
ual
re
por
tin
g of
co
mp
eten
cy
asse
ssm
ent
agai
nst
el
igib
le s
taff
Pro
gram
me
may
be
inco
rpor
ated
as
part
of
prof
essi
onal
s P
DR
pr
oces
s
1B
est
prac
tice
NH
SE (
2014
) C
QU
IN 2
014/
5 ad
diti
onal
gui
danc
e on
th
e m
enta
l hea
lth
indi
cato
r w
ww
.en
glan
d.n
hs.
uk/
wp-
con
ten
t/u
ploa
ds/2
014/
06/c
quin
-add
-mh
-gu
id.p
df
Vacc
inat
ions
Pa
tien
ts id
enti
fied
as
elig
ible
for
vacc
inat
ion
st
atu
s ar
e as
sess
ed a
nd
hav
e ou
tsta
ndi
ng
vacc
inat
ion
s of
fere
d by
pr
ovid
er
Rep
orti
ng
of
nu
mbe
r of
va
ccin
atio
ns
offe
red
and
adm
inis
tere
d
Bi-
ann
ual
re
por
tin
gR
epor
tin
g to
incl
ude
br
eakd
own
per
va
ccin
atio
n c
ateg
ory
1B
est
prac
tice
Inte
rnat
ion
al L
onge
vity
Cen
tre
(201
3) A
dult
va
ccin
atio
n –
a ke
y co
mpo
nent
of h
ealt
hy a
gein
g w
ww
.ilc
uk.
org.
uk/
inde
x.ph
p/pu
blic
atio
ns/
publ
icat
ion
_de
tails
/adu
lt_v
acci
nat
ion
_a_k
ey_c
omp
onen
t_of
_h
ealt
hy_a
gein
g
PH
E (
2014
) Im
mun
isat
ion
agai
nst i
nfec
tiou
s di
seas
e (G
reen
boo
k) w
ww
.gov
.uk/
gove
rnm
ent/
colle
ctio
ns/
imm
un
isat
ion
-aga
inst
-in
fect
iou
s-di
seas
e-th
e-gr
een
-bo
ok
This publication is being reviewed in 2019
Royal College of NuRsiNg aNd iNfeCtioN PReveNtioN soCiety
47 Return to contents
Qua
lity
requ
irem
ent
Thre
shol
d (r
epor
ting
ex
pect
atio
n)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(not
e w
here
spe
cifi
c gu
idan
ce is
not
pre
sent
this
is in
dica
ted
as ‘b
est
prac
tice
’)
Rep
orti
ng
on c
ompl
ian
ce
of h
ealt
h c
are
wor
ker
vacc
inat
ion
pro
gram
me
An
nu
al
con
firm
atio
n o
f p
erce
nta
ge o
f ac
tual
n
um
bers
an
d ty
pes
of
vac
cin
atio
n
agai
nst
elig
ible
sta
ff
An
nu
al r
epor
tin
g,
incl
udi
ng
exce
pti
ons
of
vari
atio
n t
o p
olic
y
Vac
cin
atio
n is
re
com
men
ded
not
m
anda
ted
1A
lign
s w
ith
DH
(20
15)
Cod
e of
pra
ctic
e cr
iter
ion
10
This publication is being reviewed in 2019
48
InfectIon PreventIon and control commIssIonIng toolkIt
Return to contents
App
endi
x 4:
Infe
ctio
n pr
even
tion
and
con
trol
bas
ket o
f sug
gest
ed in
dica
tors
– s
ocia
l car
e
Th
is in
dica
tor
bask
et r
ecog
nis
es a
dev
elop
men
tal a
ppro
ach
to
impr
ovem
ents
in in
fect
ion
pre
ven
tion
an
d co
ntr
ol in
adu
lt s
ocia
l car
e se
ttin
gs. I
t ac
know
ledg
es t
he
wid
e va
riat
ion
in s
ize
and
typ
e of
car
e de
liver
ed in
soc
ial c
are
sett
ings
. Sta
ge o
ne
aim
s to
su
ppor
t pr
ovid
ers
to e
nsu
re t
hei
r or
gan
isat
ion
al r
equ
irem
ents
alig
n fu
lly t
o co
mm
issi
onin
g or
gan
isat
ion
s’ e
xpec
tati
ons
of t
he
Cod
e of
Pra
ctic
e (D
H, 2
015)
. Sta
ge t
wo
build
s on
sta
ge o
ne
to fu
rth
er e
mbe
d in
fect
ion
pre
ven
tion
an
d co
ntr
ol
wit
hin
th
e or
gan
isat
ion
.
Qua
lity
re
quir
emen
tTh
resh
old
(rep
orti
ng
expe
ctat
ion)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(n
ote
whe
re s
peci
fic
guid
ance
is n
ot p
rese
nt th
is is
indi
cate
d as
‘b
est p
ract
ice’
)
Sta
ge 1
. Com
mis
sion
ing
the
fund
amen
tals
of c
lean
, saf
e ca
reA
mbi
tion
indi
cato
rsT
he
prov
ider
has
in
plac
e a
stra
tegy
th
at d
escr
ibes
its
visi
on a
nd
acti
ons
over
tim
e to
di
agn
ose,
mea
sure
, pr
even
t an
d m
anag
e pn
eum
onia
Evid
ence
of
stra
tegy
, in
clu
din
g h
ow it
will
be
revi
ewed
an
d ev
alu
ated
Evid
ence
of
stra
tegy
an
d im
plem
enta
tion
pl
an
Stra
tegy
sh
ould
in
clu
de t
he
role
of
mu
lti-
disc
iplin
ary
stak
ehol
ders
an
d co
mm
un
icat
ion
pa
thw
ays.
Stra
tegy
may
be
deve
lop
ed a
nd
imp
lem
ente
d in
co
llabo
rati
on w
ith
ot
her
pro
vide
r or
gan
isat
ion
s
1B
est
prac
tice
NIC
E C
G19
1 (2
014)
Pne
umon
ia: D
iagn
osis
and
man
agem
ent o
f co
mm
unit
y- a
nd h
ospi
tal-
acqu
ired
pne
umon
ia in
adu
lts
w
ww
.nic
e.or
g.u
k/gu
idan
ce/C
G19
1
Parl
iam
enta
ry a
nd
Hea
lth
Ser
vice
s O
mbu
dsm
an (
2014
) T
ime
to A
ct, s
ever
e se
psis
: rap
id d
iagn
osis
and
tre
atm
ent s
aves
live
s w
ww
.om
buds
man
.org
.u
k/__
data
/ass
ets/
pdf_
file
/000
4/22
666/
FIN
AL
_Sep
sis_
Rep
ort_
web
.pd
f
Th
e pr
ovid
er h
as in
pl
ace
a st
rate
gy
that
des
crib
es it
s vi
sion
an
d ac
tion
s ov
er t
ime
to
supp
ort
pati
ents
in
the
prev
enti
on,
diag
nos
is a
nd
man
agem
ent
of
uri
nar
y tr
act
infe
ctio
ns,
in
clu
din
g th
ose
that
are
not
rel
ated
to
th
e u
se o
f u
rin
ary
cath
eter
s
Evid
ence
of
stra
tegy
, in
clu
din
g h
ow it
will
be
revi
ewed
an
d ev
alu
ated
Evid
ence
of
stra
tegy
an
d im
plem
enta
tion
pl
an
Stra
tegy
sh
ould
in
clu
de t
he
role
of
mu
lti-
disc
iplin
ary
stak
ehol
ders
an
d co
mm
un
icat
ion
pa
thw
ays.
Stra
tegy
may
be
deve
lop
ed a
nd
imp
lem
ente
d in
co
llabo
rati
on w
ith
ot
her
pro
vide
r or
gan
isat
ion
s.
Not
e: m
ay a
lign
wit
h
indi
cato
r to
red
uce
th
e n
um
ber
of
un
nec
essa
ry in
vasi
ve
devi
ces
and
know
ledg
e/u
se o
f p
olic
ies
(pag
e xx
)
1, 5
Bes
t pr
acti
ce
NIC
E C
G54
(20
07)
Uri
nary
tra
ct in
fect
ion
in c
hild
ren:
Dia
gnos
is, t
reat
men
t an
d lo
ng-t
erm
man
agem
ent w
ww
.nic
e.or
g.u
k/gu
idan
ce/c
g54
NIC
E (
2014
) Q
ualit
y St
anda
rd I
nfec
tion
pre
vent
ion
and
cont
rol Q
S61
w
ww
.nic
e.or
g.u
k/gu
idan
ce/q
s61
NIC
E C
G 1
39 (
2012
) In
fect
ion:
Pre
vent
ion
and
cont
rol o
f hea
lthc
are-
asso
ciat
ed in
fect
ions
in p
rim
ary
and
com
mun
ity
care
w
ww
.nic
e.or
g.u
k/gu
idan
ce/c
g139
Parl
iam
enta
ry a
nd
Hea
lth
Ser
vice
s O
mbu
dsm
an (
2014
) T
ime
to A
ct, s
ever
e se
psis
: rap
id d
iagn
osis
and
tre
atm
ent s
aves
live
s w
ww
.om
buds
man
.org
.u
k/__
data
/ass
ets/
pdf_
file
/000
4/22
666/
FIN
AL
_Sep
sis_
Rep
ort_
web
.pd
f
NIC
E (
2015
) Q
ualit
y St
anda
rd U
rina
ry t
ract
infe
ctio
ns in
adu
lts
QS9
0
ww
w.n
ice.
org.
uk/
guid
ance
/qs9
0
NIC
E (
2013
) Q
ualit
y St
anda
rd U
rina
ry t
ract
infe
ctio
n in
infa
nts,
chi
ldre
n an
d yo
ung
peop
le u
nder
16
QS3
6 w
ww
.nic
e.or
g.u
k/gu
idan
ce/q
s36
NIC
E C
G16
1 (2
013)
Fal
ls: a
sses
smen
t and
pre
vent
ion
of fa
lls in
old
er p
eopl
e w
ww
.nic
e.or
g.u
k/gu
idan
ce/c
g161
This publication is being reviewed in 2019
Royal College of NuRsiNg aNd iNfeCtioN PReveNtioN soCiety
49 Return to contents
App
endi
x 4:
Infe
ctio
n pr
even
tion
and
con
trol
bas
ket o
f sug
gest
ed in
dica
tors
– s
ocia
l car
e
Th
is in
dica
tor
bask
et r
ecog
nis
es a
dev
elop
men
tal a
ppro
ach
to
impr
ovem
ents
in in
fect
ion
pre
ven
tion
an
d co
ntr
ol in
adu
lt s
ocia
l car
e se
ttin
gs. I
t ac
know
ledg
es t
he
wid
e va
riat
ion
in s
ize
and
typ
e of
car
e de
liver
ed in
soc
ial c
are
sett
ings
. Sta
ge o
ne
aim
s to
su
ppor
t pr
ovid
ers
to e
nsu
re t
hei
r or
gan
isat
ion
al r
equ
irem
ents
alig
n fu
lly t
o co
mm
issi
onin
g or
gan
isat
ion
s’ e
xpec
tati
ons
of t
he
Cod
e of
Pra
ctic
e (D
H, 2
015)
. Sta
ge t
wo
build
s on
sta
ge o
ne
to fu
rth
er e
mbe
d in
fect
ion
pre
ven
tion
an
d co
ntr
ol
wit
hin
th
e or
gan
isat
ion
.
Qua
lity
re
quir
emen
tTh
resh
old
(rep
orti
ng
expe
ctat
ion)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(n
ote
whe
re s
peci
fic
guid
ance
is n
ot p
rese
nt th
is is
indi
cate
d as
‘b
est p
ract
ice’
)
Sta
ge 1
. Com
mis
sion
ing
the
fund
amen
tals
of c
lean
, saf
e ca
reA
mbi
tion
indi
cato
rsT
he
prov
ider
has
in
plac
e a
stra
tegy
th
at d
escr
ibes
its
visi
on a
nd
acti
ons
over
tim
e to
di
agn
ose,
mea
sure
, pr
even
t an
d m
anag
e pn
eum
onia
Evid
ence
of
stra
tegy
, in
clu
din
g h
ow it
will
be
revi
ewed
an
d ev
alu
ated
Evid
ence
of
stra
tegy
an
d im
plem
enta
tion
pl
an
Stra
tegy
sh
ould
in
clu
de t
he
role
of
mu
lti-
disc
iplin
ary
stak
ehol
ders
an
d co
mm
un
icat
ion
pa
thw
ays.
Stra
tegy
may
be
deve
lop
ed a
nd
imp
lem
ente
d in
co
llabo
rati
on w
ith
ot
her
pro
vide
r or
gan
isat
ion
s
1B
est
prac
tice
NIC
E C
G19
1 (2
014)
Pne
umon
ia: D
iagn
osis
and
man
agem
ent o
f co
mm
unit
y- a
nd h
ospi
tal-
acqu
ired
pne
umon
ia in
adu
lts
w
ww
.nic
e.or
g.u
k/gu
idan
ce/C
G19
1
Parl
iam
enta
ry a
nd
Hea
lth
Ser
vice
s O
mbu
dsm
an (
2014
) T
ime
to A
ct, s
ever
e se
psis
: rap
id d
iagn
osis
and
tre
atm
ent s
aves
live
s w
ww
.om
buds
man
.org
.u
k/__
data
/ass
ets/
pdf_
file
/000
4/22
666/
FIN
AL
_Sep
sis_
Rep
ort_
web
.pd
f
Th
e pr
ovid
er h
as in
pl
ace
a st
rate
gy
that
des
crib
es it
s vi
sion
an
d ac
tion
s ov
er t
ime
to
supp
ort
pati
ents
in
the
prev
enti
on,
diag
nos
is a
nd
man
agem
ent
of
uri
nar
y tr
act
infe
ctio
ns,
in
clu
din
g th
ose
that
are
not
rel
ated
to
th
e u
se o
f u
rin
ary
cath
eter
s
Evid
ence
of
stra
tegy
, in
clu
din
g h
ow it
will
be
revi
ewed
an
d ev
alu
ated
Evid
ence
of
stra
tegy
an
d im
plem
enta
tion
pl
an
Stra
tegy
sh
ould
in
clu
de t
he
role
of
mu
lti-
disc
iplin
ary
stak
ehol
ders
an
d co
mm
un
icat
ion
pa
thw
ays.
Stra
tegy
may
be
deve
lop
ed a
nd
imp
lem
ente
d in
co
llabo
rati
on w
ith
ot
her
pro
vide
r or
gan
isat
ion
s.
Not
e: m
ay a
lign
wit
h
indi
cato
r to
red
uce
th
e n
um
ber
of
un
nec
essa
ry in
vasi
ve
devi
ces
and
know
ledg
e/u
se o
f p
olic
ies
(pag
e xx
)
1, 5
Bes
t pr
acti
ce
NIC
E C
G54
(20
07)
Uri
nary
tra
ct in
fect
ion
in c
hild
ren:
Dia
gnos
is, t
reat
men
t an
d lo
ng-t
erm
man
agem
ent w
ww
.nic
e.or
g.u
k/gu
idan
ce/c
g54
NIC
E (
2014
) Q
ualit
y St
anda
rd I
nfec
tion
pre
vent
ion
and
cont
rol Q
S61
w
ww
.nic
e.or
g.u
k/gu
idan
ce/q
s61
NIC
E C
G 1
39 (
2012
) In
fect
ion:
Pre
vent
ion
and
cont
rol o
f hea
lthc
are-
asso
ciat
ed in
fect
ions
in p
rim
ary
and
com
mun
ity
care
w
ww
.nic
e.or
g.u
k/gu
idan
ce/c
g139
Parl
iam
enta
ry a
nd
Hea
lth
Ser
vice
s O
mbu
dsm
an (
2014
) T
ime
to A
ct, s
ever
e se
psis
: rap
id d
iagn
osis
and
tre
atm
ent s
aves
live
s w
ww
.om
buds
man
.org
.u
k/__
data
/ass
ets/
pdf_
file
/000
4/22
666/
FIN
AL
_Sep
sis_
Rep
ort_
web
.pd
f
NIC
E (
2015
) Q
ualit
y St
anda
rd U
rina
ry t
ract
infe
ctio
ns in
adu
lts
QS9
0
ww
w.n
ice.
org.
uk/
guid
ance
/qs9
0
NIC
E (
2013
) Q
ualit
y St
anda
rd U
rina
ry t
ract
infe
ctio
n in
infa
nts,
chi
ldre
n an
d yo
ung
peop
le u
nder
16
QS3
6 w
ww
.nic
e.or
g.u
k/gu
idan
ce/q
s36
NIC
E C
G16
1 (2
013)
Fal
ls: a
sses
smen
t and
pre
vent
ion
of fa
lls in
old
er p
eopl
e w
ww
.nic
e.or
g.u
k/gu
idan
ce/c
g161
Qua
lity
re
quir
emen
tTh
resh
old
(rep
orti
ng
expe
ctat
ion)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(n
ote
whe
re s
peci
fic
guid
ance
is n
ot p
rese
nt th
is is
indi
cate
d as
‘b
est p
ract
ice’
)
Th
e pr
ovid
er h
as in
pl
ace
a st
rate
gy
that
des
crib
es
acti
ons
to r
ecog
nis
e m
easu
re a
nd
man
age
susp
ecte
d ca
ses
of s
epsi
s
Evid
ence
of
stra
tegy
, in
clu
din
g h
ow it
will
be
revi
ewed
an
d ev
alu
ated
Evid
ence
of
stra
tegy
an
d im
plem
enta
tion
pl
an
Stra
tegy
sh
ould
in
clu
de t
he
role
of
mu
lti-
disc
iplin
ary
stak
ehol
ders
an
d co
mm
un
icat
ion
pa
thw
ays.
St
rate
gy m
ay b
e de
velo
ped
an
d im
ple
men
ted
in
colla
bora
tion
wit
h
oth
er p
rovi
der
orga
nis
atio
ns
1, 2
NH
S E
ngl
and
(201
5) C
omm
issi
onin
g fo
r qu
alit
y an
d in
nova
tion
(C
QU
IN)
Gui
danc
e fo
r 20
15/1
6 w
ww
.en
glan
d.n
hs.
uk/
wp-
con
ten
t/u
ploa
ds/2
015/
03/9
-cqu
in-g
uid
-201
5-16
Parl
iam
enta
ry a
nd
Hea
lth
Ser
vice
s O
mbu
dsm
an (
2014
) T
ime
to A
ct, s
ever
e se
psis
: rap
id d
iagn
osis
and
tre
atm
ent s
aves
live
s w
ww
.om
buds
man
.org
.u
k/__
data
/ass
ets/
pdf_
file
/000
4/22
666/
FIN
AL
_Sep
sis_
Rep
ort_
web
.pd
f
An
infe
ctio
n
prev
enti
on le
ad is
id
enti
fied
an
d cl
earl
y vi
sibl
e in
th
e or
gan
isat
ion
Nam
e of
lead
Incl
ude
d in
an
nu
al s
tate
men
t an
d is
pu
blic
ally
av
aila
ble
A r
ole
desc
rip
tion
an
d/or
job
desc
rip
tion
sh
ould
be
avai
labl
e
1A
lign
s w
ith
DH
(20
15)
Cod
e of
pra
ctic
e
Polic
ies
are
in p
lace
an
d st
aff
are
awar
e of
th
eir
con
ten
t in
th
e fo
llow
ing
key
area
s
Pri
orit
ised
p
olic
ies
rela
tin
g to
IP
C in
clu
de:
• han
d hy
gien
e
• env
iron
men
tal
clea
nlin
ess
• sta
nda
rd
prec
auti
ons
• man
agem
ent
of
uri
nar
y ca
thet
ers
• en
tera
l fee
din
g
• IV
th
erap
y
To b
e av
aila
ble
at
tim
e of
in
spec
tion
or
qual
ity
revi
ew
visi
t an
d m
ade
publ
icly
ava
ilabl
e
Loca
l pro
fess
ion
al
net
wor
ks c
an b
e u
sed
as a
met
hod
of
deve
lopi
ng
pol
icie
s an
d gu
idan
ce
1A
lign
s w
ith
DH
(20
15)
Cod
e of
pra
ctic
e
NIC
E (
2012
) C
G 1
39 I
nfec
tion
: Pre
vent
ion
and
cont
rol o
f hea
lthc
are-
asso
ciat
ed in
fect
ions
in p
rim
ary
and
com
mun
ity
care
w
ww
.nic
e.or
g.u
k/gu
idan
ce/c
g139
This publication is being reviewed in 2019
50
InfectIon PreventIon and control commIssIonIng toolkIt
Return to contents
Qua
lity
re
quir
emen
tTh
resh
old
(rep
orti
ng
expe
ctat
ion)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(n
ote
whe
re s
peci
fic
guid
ance
is n
ot p
rese
nt th
is is
indi
cate
d as
‘b
est p
ract
ice’
)
Loca
l med
icin
es
man
agem
ent
pol
icie
s in
clu
de
anti
biot
ic
pres
crib
ing
and
adm
inis
trat
ion
. R
eflec
ts n
atio
nal
pr
escr
ibin
g gu
idan
ce
Pre
sen
ce o
f m
edic
ines
m
anag
emen
t p
olic
y
An
nu
al
con
firm
atio
n o
f p
olic
y in
pla
ce
and
evid
ence
of
colla
bora
tive
w
orki
ng
wit
h
oth
er a
gen
cies
(n
ote:
may
cro
ss-
refe
ren
ce w
ith
pr
imar
y an
d co
mm
un
ity
bask
et)
Polic
y ca
n b
e de
velo
ped
wit
h lo
cal
prim
ary
care
pr
ovid
ers
(GPs
) to
su
ppor
t st
and
ardi
sati
on o
f pr
acti
ce fo
r an
tibi
otic
pr
escr
ibin
g. P
olic
y sh
ould
be
revi
ewed
m
inim
um
of
two-
year
ly u
nle
ss n
ew
nat
ion
al g
uid
ance
is
sued
2N
ICE
SC
1 (2
014)
Man
agin
g m
edic
ines
in c
are
hom
es
ww
w.n
ice.
org.
uk/
guid
ance
/sc1
Alig
ns
wit
h D
H (
2015
) C
ode
of p
ract
ice
NIC
E (
2014
) Q
ualit
y St
anda
rd I
nfec
tion
pre
vent
ion
and
cont
rol Q
S61
ww
w.n
ice.
org.
uk/
guid
ance
/qs6
1
NIC
E G
uid
elin
e N
G15
(20
15)
Ant
imic
robi
al s
tew
ards
hip:
sys
tem
s an
d pr
oces
ses
for
effe
ctiv
e an
tim
icro
bial
med
icin
e us
e w
ww
.nic
e.or
g.u
k/gu
idan
ce/
NG
15/c
hap
ter/
2-Im
plem
enta
tion
-get
tin
g-st
arte
d
All
staf
f h
ave
acce
ss
to r
esou
rces
to
supp
ort
han
d hy
gien
e at
th
e p
oin
t of
car
e w
hen
in
dica
ted
Evid
ence
of
how
re
sou
rces
are
pr
ovid
ed a
nd
use
d in
pra
ctic
e
Six-
mon
thly
re
view
Req
uir
emen
ts a
re fo
r lo
cal d
eter
min
atio
n
base
d on
pat
ien
t p
opu
lati
on a
nd
serv
ice
sett
ing
1N
ICE
(20
14)
Qua
lity
Stan
dard
QS6
1 w
ww
.nic
e.or
g.u
k/gu
idan
ce/q
s61
NIC
E C
G 1
39 (
2012
) In
fect
ion:
Pre
vent
ion
and
cont
rol o
f hea
lthc
are-
asso
ciat
ed in
fect
ions
in p
rim
ary
and
com
mun
ity
care
w
ww
.nic
e.or
g.u
k/gu
idan
ce/c
g139
Pro
vide
r’s
inci
den
t re
por
tin
g sy
stem
in
clu
des
infe
ctio
n
inci
den
ts
Infe
ctio
n
inci
den
ts a
re
reco
rded
an
d
rep
orte
d to
th
e co
mm
issi
oner
Mon
thly
re
por
tin
gE
xam
ples
of
inci
den
ts in
clu
de
indw
ellin
g de
vice
-re
late
d in
fect
ion
s,
nu
mbe
r of
clo
sed
hom
e da
ys/b
eds
1D
H (
2015
) C
ode
of p
ract
ice
NH
S E
ngl
and
(201
3) S
erio
us in
cide
nt fr
amew
ork
w
ww
.en
glan
d.n
hs.
uk/
wp-
con
ten
t/u
ploa
ds/2
013/
03/s
if-g
uid
e.pd
f
HPA
(20
12)
Hea
lthc
are
asso
ciat
ed in
fect
ion
oper
atio
nal g
uida
nce
and
stan
dard
s fo
r he
alth
pro
tect
ion
unit
s w
ww
.gov
.uk/
gove
rnm
ent/
pu
blic
atio
ns/
hea
lth
care
-ass
ocia
ted-
infe
ctio
n-h
cai-
oper
atio
nal
-gu
idan
ce-a
nd
-sta
nd
ard
s
IPC
is in
clu
ded
as a
re
gula
r ag
enda
it
em in
pro
vide
r or
gan
isat
ion
m
eeti
ngs
Rec
ord
of
mee
tin
gs a
nd
IPC
to
pics
dis
cuss
ed
Min
ute
s of
m
eeti
ngs
Pro
vide
r to
de
term
ine
wh
ich
m
eeti
ngs
will
ro
uti
nel
y in
clu
de I
PC
di
scu
ssio
n
1B
est
prac
tice
This publication is being reviewed in 2019
Royal College of NuRsiNg aNd iNfeCtioN PReveNtioN soCiety
51 Return to contents
Qua
lity
re
quir
emen
tTh
resh
old
(rep
orti
ng
expe
ctat
ion)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(n
ote
whe
re s
peci
fic
guid
ance
is n
ot p
rese
nt th
is is
indi
cate
d as
‘b
est p
ract
ice’
)
Cop
ies
of a
ll re
por
ts a
nd
asso
ciat
ed a
ctio
n
plan
s in
res
pon
se
to a
ny e
xter
nal
IP
C
focu
s vi
sits
/in
spec
tion
s (e
.g.
from
CC
G, C
QC
, Lo
cal A
uth
orit
y)
are
mad
e av
aila
ble
to t
he
com
mis
sion
er b
y th
e pr
ovid
er
Cop
ies
of r
epor
ts
sen
t to
co
mm
issi
oner
w
ith
in fi
ve
wor
kin
g d
ays
of
the
prov
ider
re
ceiv
ing
the
rep
ort
Rep
orts
are
re
ceiv
ed1
Bes
t pr
acti
ce
Edu
cati
on/t
rain
ing
All
staf
f re
ceiv
e IP
C t
rain
ing
at
indu
ctio
n
An
nu
al
rep
orti
ng
of
per
cen
tage
, n
amed
pro
vide
r of
tra
inin
g an
d ou
tlin
e of
th
e pr
ogra
mm
e
1,3
Alig
ns
wit
h D
H (
2015
) C
ode
of p
ract
ice
NIC
E C
G 1
39 (
2012
) In
fect
ion:
Pre
vent
ion
and
cont
rol o
f hea
lthc
are-
asso
ciat
ed in
fect
ions
in p
rim
ary
and
com
mun
ity
care
w
ww
.nic
e.or
g.u
k/gu
idan
ce/c
g139
Th
e pr
ovid
er
deve
lops
a
prog
ram
me
of
infe
ctio
n
prev
enti
on a
udi
ts
linke
d to
cor
e IP
C
pol
icie
s
Evid
ence
of
audi
t pr
ogra
mm
e,
com
ple
ted
audi
t re
sult
s an
d an
y as
soci
ated
act
ion
pl
ans
Qu
arte
rly
rep
orti
ng.
In
form
atio
n t
o be
ava
ilabl
e at
ti
me
of
insp
ecti
on o
r qu
alit
y re
view
vi
sit
and
avai
labl
e to
th
e pu
blic
in I
PC
an
nu
al r
epor
t
1A
lign
s w
ith
DH
(20
15)
Cod
e of
pra
ctic
e
This publication is being reviewed in 2019
52
InfectIon PreventIon and control commIssIonIng toolkIt
Return to contents
Qua
lity
re
quir
emen
tTh
resh
old
(rep
orti
ng
expe
ctat
ion)
Met
hod
of
mea
sure
men
tCo
mm
ents
CMO
st
rate
gy
acti
on
area
Evid
ence
/su
ppor
ting
sou
rce
(n
ote
whe
re s
peci
fic
guid
ance
is n
ot p
rese
nt th
is is
indi
cate
d as
‘b
est p
ract
ice’
)
Pro
vide
r co
ntr
ibu
tes
and
coop
erat
es w
ith
th
e Po
st I
nfe
ctio
n
Rev
iew
(P
IR)
/R
CA
/ ‘L
apse
in
care
’ inv
esti
gati
ons
for
all c
ases
of
HC
AI,
incl
udi
ng
MR
SA b
acte
raem
ia
and
C. d
iffic
ile
infe
ctio
n
Con
trib
uti
on t
o th
e P
IR p
roce
ss
and
im
plem
enta
tion
of
act
ion
pla
ns
and
lear
nin
g de
rive
d fr
om
inve
stig
atio
n
revi
ews.
10
0% a
tten
dan
ce
at in
vest
igat
ion
m
eeti
ngs
Att
enda
nce
at
PIR
mee
tin
gs.
Act
ion
pla
n
rep
orts
are
re
ceiv
ed a
nd
upd
ated
wh
ere
appl
icab
le
regu
larl
y by
pr
ovid
er, w
ith
le
arn
ing
shar
ed
acro
ss t
he
orga
nis
atio
n
Wit
h e
xcep
tion
s of
M
RSA
bac
tera
emia
an
d C
. dif
ficile
in
fect
ion
, oth
er
HC
AIs
th
at r
equ
ire
inve
stig
atio
n a
re t
o be
det
erm
ined
loca
lly
1N
HS
En
glan
d (2
014)
Zer
o to
lera
nce
w
ww
.en
glan
d.n
hs.
uk/
pati
ents
afet
y/as
soci
ated
-in
fect
ion
s/ze
ro-t
oler
ance
/
NH
S E
ngl
and
(201
5) C
lost
ridi
um
dif
fici
le in
fect
ion
obje
ctiv
es fo
r N
HS
orga
nisa
tion
s in
201
5/16
and
gui
danc
e on
san
ctio
n im
plem
enta
tion
w
ww
.en
glan
d.n
hs.
uk/
wp-
con
ten
t/u
ploa
ds/2
015/
02/c
lost
ridm
-dif
fici
le-
infe
ct-o
bjct
-15-
16-g
uid
-feb
15.p
df
Susp
ecte
d or
co
nfi
rmed
ou
tbre
aks
are
rep
orte
d to
th
e co
mm
issi
oner
an
d lo
cal h
ealt
h
prot
ecti
on t
eam
All
outb
reak
s ar
e re
por
ted
on t
he
sam
e da
y
Mon
thly
re
por
tin
g to
th
e co
mm
issi
oner
1,5
Car
e Q
ual
ity
Com
mis
sion
(20
15)
guid
ance
w
ww
.cqc
.org
.uk/
con
ten
t/n
otifi
cati
ons-
non
-nh
s-tr
ust
-pro
vide
rs
Th
e pr
ovid
er h
as a
sy
stem
in p
lace
to
supp
ort
prep
ared
nes
s or
m
anag
emen
t of
pa
tien
ts c
arry
ing
carb
apen
emas
e-pr
odu
cin
g E
nte
roba
cter
iace
ae
(CP
E)
in li
ne
wit
h
PH
E C
PE
gu
idan
ce
Th
e pr
ovid
er h
as
a p
olic
y in
pla
ce
for
the
man
agem
ent
of
CP
E a
nd
has
co
nsi
dere
d th
e im
plic
atio
ns
of it
s im
plem
enta
tion
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This publication is being reviewed in 2019
Royal College of NuRsiNg aNd iNfeCtioN PReveNtioN soCiety
53 Return to contents
Qua
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This publication is being reviewed in 2019
54
InfectIon PreventIon and control commIssIonIng toolkIt
Return to contents
Qua
lity
re
quir
emen
tTh
resh
old
(rep
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ng
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ctat
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This publication is being reviewed in 2019
Royal College of NuRsiNg aNd iNfeCtioN PReveNtioN soCiety
55 Return to contents
Qua
lity
re
quir
emen
tTh
resh
old
(rep
orti
ng
expe
ctat
ion)
Met
hod
of
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aspx
This publication is being reviewed in 2019
56
InfectIon PreventIon and control commIssIonIng toolkIt
Return to contents
• Commissionersshouldengagewithsocialcareproviderstoassistintheirattainmentof,andcompliancewith,theCode of practice,forexampleinrelationtofundednursingcareplacementsandthecontractsthatCCGsmayhavewithnursinghomestodeliverthis;however,thiscouldalsobeajointcommissioningrelationshipbetweenhealthandsocialcare.
Contracting and setting standards
Aim: to ensure national and local IPC standards are set at the correct level and included in contracts with provider organisations.
• EnsurethereareservicespecificationsforIPC,specific/relevantkeyperformanceindicators(KPIs)andqualityindicatorsinprovidercontracts.AsaminimumthesemustbeconsistentwithThe NHS Planning Guidance 2016/17 – 2020/21andothernationalmandatorypolicies.Seethebasketofsuggestedindicators.
• SupportengagementwithqualityimprovementinitiativesasappropriatethroughCommissioning for quality and innovation(CQUIN)development(NHSE,2015).
• Accesslocalinfectionpreventionteams/expertstoensureinfectionpreventioninputoccursinthedevelopmentofallnewcontracts,servicesandpathways.
Objective: to have a collaborative approach to the prevention and management of HCAI and antimicrobial resistance (AMR) in the health and social care economy.
Aim: to develop systems in collaboration with all stakeholders that are fit for purpose, and which will support delivery of the HCAI/safety agenda.
• NHSEngland,clinicalcommissioninggroups(CCGs)andlocalauthoritiesworkingwithhealthandsocialcareprovidersshouldhaveappropriatestrategiesforthepreventionandcontrolofhealthcareassociatedinfectionswithclearresponsibilities.
• Ahealthandsocialcareeconomy-wideHCAIandAMRnetwork.
• Ahealthandsocialcareeconomycollaborativemeetingthathassign-upfromchiefexecutivesanddirectors.
• Infectionpreventionandcontrol(IPC)strategybasedonajointstrategicneedsassessment,whichissupportedbyandagreedbythehealtheconomy.ThisinturnwillsupportindividualproviderorganisationIPCstrategies,andsitaspartoftheoverarchingqualityandsafetystrategyforthecommissioningorganisation.
• Commissionersshouldusethehealtheconomynetworktoinitiateandleadontheimplementationofnational/regionalandlocalprogrammes,inlinewithNHSEnglandpolicies:
- Everyone counts, planning for patients 2014/15 to 2018/19;
- NHS outcomes framework 2015/16
- Adult social care outcomes framework 2015/16.
Appendix 5: Leading and developing the health care associated infection (HCAI) system
This publication is being reviewed in 2019
Royal College of NuRsiNg aNd iNfeCtioN PReveNtioN soCiety
57 Return to contents
Quality assurance
Aim: to monitor performance against all shared objectives and KPIs from all providers.
• Commissionerorganisationsshouldparticipateinperformance monitoring and quality assurance arrangements for each provider. For example, through:
- attendance at provider infection prevention committees and review meetings with provider IPC leads as agreed locally
- regular formal HCAI performance monitoring meetings with contract management staff
- input into the overarching contract quality meeting/clinical quality review groups
- receipt of regular infection prevention/HCAI dashboards from providers
- inspections and visits.
• Commissioningorganisationsshouldhaveaccesstoappropriate IPC expertise to interpret data or information received from providers.
• Analyseinformationsubmittedbyprovidersanddetermine whether the information offers the required assurance.
• Commissionersshouldbeincludedininternalperformance monitoring arrangements for primary care, such as the performance management group or annual contract review processes. It is through this mechanism that environmental audits to assess environmental fitness for purpose can be fed into the overarching performance framework.
• IPCshouldfeatureinthecommissioningframework about fitness to practise, as commissioning decisions are made about the transfer of care from secondary to primary. For example, is the environment fit for purpose?
• Engagewithprimarycarecontractingtodeveloprobust assurance of infection prevention practice across primary care providers as the commissioning processes evolve.
• EnsurethatthereisspecialistIPCpractitionerinputwithin provider settings into IPC-related contracts such as:
- cleaning
- catering
- planned preventive maintenance (PPM)
- building construction and refurbishment
- waste management.
Health care associated infection reduction plan
The provider must have an HCAI reduction plan for each contract year and must comply with its obligations under that plan. The HCAI reduction plan must reflect local and national priorities relating to HCAI, including AMR (NHS Standard Contract, NHS England 2015).
The purpose of an HCAI reduction plan is to outline the provider’s approach to the prevention and control of HCAIs and AMR. All providers will be expected to have in place annual programmes of work to ensure that standards and objectives are met according to agreed contractual indicators and national and local objectives for reducing HCAI and AMR. This activity will be monitored on a locally agreed basis through formal reporting mechanisms established through the integrated quality teams and contract and performance monitoring systems, ensuring key expectations are fulfilled.
This publication is being reviewed in 2019
58
InfectIon PreventIon and control commIssIonIng toolkIt
Return to contents
• IPCcommissioningarrangementsareembeddedinthe commissioning organisation’s governance processes.
• Thereisanescalationprocessinplace.HCAI/AMRis added, where necessary, to the corporate risk register of the commissioning organisation.
• Infectionpreventionisanintegralpartofthecapital programme for new build premises and refurbishments to ensure IPC standards are met and buildings are fit-for-purpose.
• IPCisincludedaspartoftheemergencyplanningprocess.
• Engageproactivelywithhealthandwellbeingboards to provide assurance that local population risks and needs are adequately understood, addressed and evaluated via existing commissioning processes in relation to IPC and antimicrobial resistance (AMR).
Organisational accountability in commissioning organisations
Aim: to ensure infection prevention and control is embedded and that board accountability/assurance is demonstrated.
• Thecommissioningorganisationhasaclearunderstanding of its commissioned services, IPC status and risks and has sufficient specialist IPC support/resources available to enable it to meet its responsibilities for quality and safety of the services provided. IPC is included as an integral part of the commissioning organisation’s internal quality and safety monitoring and assurance systems.
• Thecommissioningorganisationhasaclearprocessfor providing assurance to NHS England with regard to HCAI and AMR standards and risks.
• Thecommissioningorganisationhasastrategicandoperational plan for reducing HCAI and AMR and sustaining improvement of infection prevention practices. Accurate and timely information that includes the quality dashboard and all other relevant performance matrix is reported to the organisational governance framework, and shared with relevant commissioning bodies.
• Informationismonitoredmonthlybytheinfectionprevention and integrated quality teams. Formal reports analysing quality and performance, action plans and exceptions are made to the approved committee in the commissioning organisation. Annual reports provide a summary of activity, assurance and risks to the board.
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Department of Health (2015) Code of practice on the prevention and control of infections and related guidance www.gov.uk/government/publications/the-health-and-social-care-act-2008-code-of-practice-on-the-prevention-and-control-of-infections-and-related-guidance
Health Education England (2015) Prevention and public health action plan https://hee.nhs.uk/our-work/hospitals-primary-community-care/prevention-public-health-wellbeing-0
Health Matters blog https://publichealthmatters.blog.gov.uk/2015/12/10/health-matters-tackling-antimicrobial-resistance/
Health Protection Agency (2012) English national point prevalence survey on healthcare-associated infections and antimicrobial use, 2011. Preliminary data. London: Health Protection Agency. www.gov.uk/government/uploads/system/uploads/attachment_data/file/331871/English_National_Point_Prevalence_Survey_on_Healthcare_associated_Infections_and_Antimicrobial_Use_2011.pdf
Health Protection Agency (2012) Healthcare associated infection operational guidance and standards for health protection units www.gov.uk/government/publications/healthcare-associated-infection-hcai-operational-guidance-and-standards
International Longevity Centre (2013) Adult vaccination – a key component of healthy ageing www.ilcuk.org.uk/index.php/publications/publication_details/adult_vaccination_a_key_component_of_healthy_ageing
Monitor (2015) Risk assessment framework. London: Monitor. www.gov.uk/government/publications/risk-assessment-framework-raf
NHS England (2013) Everyone counts, planning for patients 2014/15 to 2018/19. London: NHSE. www.england.nhs.uk/wp-content/uploads/2013/12/5yr-strat-plann-guid-wa.pdf
Care Quality Commission (2015) Guidance for providers on meeting the regulations www.cqc.org.uk/content/regulations-service-providers-and-managers
Care Quality Commission (2015) The scope of registration. London: CQC. www.cqc.org.uk/file/4525
Daniels R (2011) Surviving the first hours in sepsis: getting the basics right (an intensivist’s perspective). Journal of Antimicrobial Chemotherapy; 66 (Suppl ii): 11-23
Department of Health (2011) Start SMART then focus www.gov.uk/government/publications/antimicrobial-stewardship-start-smart-then-focus
Department of Health (2013) The NHS outcomes framework 2015/165. London: DH. Available at www.gov.uk/government/publications/nhs-outcomes-framework-2015-to-2016
Department of Health (2014) Implementation of modified admission MRSA screening guidance for NHS www.gov.uk/government/uploads/system/uploads/attachment_data/file/345144/Implementation_of_modified_admission_MRSA_screening_guidance_for_NHS.pdf
Department of Health (2014) The mandate. A mandate to the Government to NHS England: April 2014 to March 2015, London. DH. www.gov.uk/government/uploads/system/uploads/attachment_data/file/383495/2902896_DoH_Mandate_Accessible_v0.2.pdf
Department of Health (2015) Public health outcomes framework www.gov.uk/government/publications/healthy-lives-healthy-people-improving-outcomes-and-supporting-transparency
Department of Health (2015) The adult social care outcomes framework 2015 to 2016 www.gov.uk/government/publications/the-adult-social-care-outcomes-framework-2013-to-2014
References and further reading
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InfectIon PreventIon and control commIssIonIng toolkIt
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NHS England (2013) Serious incident framework www.england.nhs.uk/wp-content/uploads/2013/03/sif-guide.pdf
NHS England (2014) CQUIN 2014/5 additional guidance on the mental health indicator www.england.nhs.uk/wp-content/uploads/2014/06/cquin-add-mh-guid.pdf
NHS England (2014) Five year forward view www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf
NHS England (2014) Zero tolerance www.england.nhs.uk/patientsafety/associated-infections/zero-tolerance/
NHS England (2015) Commissioning for quality and innovation (CQUIN) Guidance for 2015/16 www.england.nhs.uk/wp-content/uploads/2015/03/9-cquin-guid-2015-16.pdf
NHS England (2015) Standard contract www.england.nhs.uk/nhs-standard-contract/15-16/
NHS England (2015) Clostridium difficile infection objectives for NHS organisations in 2015/16 and guidance on sanction implementation www.england.nhs.uk/wp-content/uploads/2015/02/clostridm-difficile-infect-objct-15-16-guid-feb15.pdf
NHS Trust Development Authority (2015) Delivering for patients: the 2015/16 accountability framework for NHS trust boards.
National Institute for Health and Care Excellence (2007) CG54 Urinary tract infection in children: Diagnosis, treatment and long-term management www.nice.org.uk/guidance/cg54
National Institute for Health and Care Excellence (2012) CG 139 Infection: Prevention and control of healthcare-associated infections in primary and community care www.nice.org.uk/guidance/cg139
National Institute for Health and Care Excellence (2013) Guidelines CG161 Falls in older people: assessing risk and prevention www.nice.org.uk/guidance/cg161
National Institute for Health and Care Excellence (2013) Quality standard QS36 urinary tract infection in infants, children and young people under 16 www.nice.org.uk/guidance/qs36
National Institute for Health and Care Excellence (2014) Clinical guideline 191. Pneumonia. Diagnosis and management of community- and hospital-acquired pneumonia in adults.
National Institute for Health and Care Excellence (2014) Managing medicines in care homes www.nice.org.uk/guidance/sc1
National Institute for Health and Care Excellence (2014) Quality Standard Infection prevention and control QS61 www.nice.org.uk/guidance/qs61
National Institute for Health and Care Excellence (2015) Quality Standard Urinary tract infections in adults QS90 www.nice.org.uk/guidance/qs90
National Institute for Health and Care Excellence (2015) Guideline NG15 Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use www.nice.org.uk/guidance/NG15/chapter/2-Implementation-getting-started
Parliamentary and Health Service Ombudsman (2014) Time to Act. Severe sepsis: rapid diagnosis and treatment. London. Parliamentary and Health Service Ombudsman available at http://sepsisappg.com/wp-content/uploads/2014/02/FINAL_Sepsis_Report_web.pdf
Public Health England (2013) Acute trust toolkit for the early detection, management and control of carbapenemase-producing Enterobacteriaceae www.gov.uk/government/publications/carbapenemase-producing-enterobacteriaceae-early-detection-management-and-control-toolkit-for-acute-trusts
Public Health England (2013) Antimicrobial prescribing and stewardship competencies www.gov.uk/government/uploads/system/uploads/attachment_data/file/253094/ARHAIprescrcompetencies__2_.pdf
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Further reading
Infection Prevention Society Quality Improvement tools www.ips.uk.net/professional-practice/quality-improvement-tools/#.VqZReOiLSUl [accessed 25 November 2015]
NHS England, Sign up to safety www.england.nhs.uk/signuptosafety/ [accessed 25 November 2015]
NHS England resources for Clinical Commissioning Groups (CCGs) www.england.nhs.uk/resources/resources-for-ccgs/
NHS England (2014) Guidance on the reporting and monitoring arrangements and post infection review process for MRSA bloodstream infections from April 2014 (version 2)
Loveday HP, Wilson JA and Pratt RJ et al (2014) Epic 3: National Evidence-based Guidelines for prevention healthcare associated infections in NHS hospitals in England. Journal of Hospital Infection 86S1 s1-70 Available at www.his.org.uk/files/3113/8693/4808/epic3_National_Evidence-Based_Guidelines_for_Preventing_HCAI_in_NHSE.pdf [accessed 16 July 2014]
Public Health England (2013) Immunisation against infectious disease (Green book) www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book
RCN (2009) Measuring for quality in health and social care: An RCN position statement. London: RCN
RCN (2011) RCN link nurse framework www2.rcn.org.uk/__data/assets/pdf_file/0006/481515/004310.pdf
RCN (2014) Antimicrobial resistance. RCN position on the nursing contribution. London: RCN
RCN (2015) Infection prevention and control within health and social care: commissioning, performance management and regulation arrangement (England). London: RCN
Scottish Intercollegiate Guidelines Network (2012) SIGN 88. Management of suspected bacterial urinary tract infection in adults. A national clinical guideline. Edinburgh: SIGN.
This publication is being reviewed in 2019
The RCN represents nurses and nursing, promotes excellence in practice and shapes health policies
A joint RCN and IPS publication
Second edition: January 2016 Review date: January 2018
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This publication is being reviewed in 2019