programme against the National Standards for the prevention ......Page 1 of 30 Guide to HIQA’s targeted monitoring programme against the National Standards for the prevention and

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Guide to HIQA’s targeted monitoring

programme against the National Standards

for the prevention and control of healthcare-

associated infections in acute healthcare

services during the COVID-19 pandemic

September 2020

Guide to HIQA’s targeted monitoring programme against the National Standards for the prevention and control of

healthcare-associated infections in acute healthcare services during the COVID-19 pandemic

Health Information and Quality Authority

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About the Health Information and Quality Authority (HIQA)

The Health Information and Quality Authority (HIQA) is an independent statutory

authority established to promote safety and quality in the provision of health and

social care services for the benefit of the health and welfare of the public.

HIQA’s mandate to date extends across a wide range of public, private and voluntary

sector services. Reporting to the Minister for Health and engaging with the Minister

for Children and Youth Affairs, HIQA has responsibility for the following:

Setting standards for health and social care services — Developing

person-centred standards and guidance, based on evidence and international

best practice, for health and social care services in Ireland.

Regulating social care services — The Chief Inspector within HIQA is

responsible for registering and inspecting services for older people and people

with a disability, and children’s special care units.

Regulating health services — Regulating medical exposure to ionising

radiation.

Monitoring services — Monitoring the safety and quality of health services

and children’s social services, and investigating as necessary serious concerns

about the health and welfare of people who use these services.

Health technology assessment — Evaluating the clinical and cost-

effectiveness of health programmes, policies, medicines, medical equipment,

diagnostic and surgical techniques, health promotion and protection activities,

and providing advice to enable the best use of resources and the best

outcomes for people who use our health service.

Health information — Advising on the efficient and secure collection and

sharing of health information, setting standards, evaluating information

resources and publishing information on the delivery and performance of

Ireland’s health and social care services.

National Care Experience Programme — Carrying out national service-

user experience surveys across a range of health services, in conjunction with

the Department of Health and the HSE.




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Contents

Section 1: Overview ............................................................................................. 5

1.1 Introduction ................................................................................................ 5

1.2 Aim of this programme ................................................................................ 5

1.3 The purpose of this guide ............................................................................ 6

1.4 General queries in relation to this programme ............................................... 6

Section 2: How HIQA will inspect through this monitoring programme ..................... 7

2.1 Inspection teams ......................................................................................... 7

2.2 Before an inspection .................................................................................... 7

2.3 Public health precautions during inspection ................................................... 7

2.4 On-site fieldwork ......................................................................................... 8

2.5 The day of inspection .................................................................................. 8

2.6 Documentation, data and information request ............................................... 9

2.7 Confidentiality ............................................................................................. 9

2.8 Meetings ................................................................................................... 10

2.9 Clinical area inspections ............................................................................. 10

2.10 Close-out meeting ................................................................................... 10

2.11 Risk management and escalation .............................................................. 11

2.12 HIQA’s inspection report .......................................................................... 11

2.13 Freedom of Information ........................................................................... 13

Section 3: National Standards ............................................................................. 14

3.1 Quality and safety ..................................................................................... 15

3.2 Capacity and capability .............................................................................. 15

3.3 Standards for review under this monitoring programme ............................... 15

Section 4: Guidance for assessment judgment framework..................................... 17

4.1 Assessment judgment framework ............................................................... 17

Bibliography ....................................................................................................... 25

Appendix 1 Sample documentation and data request for review on the day of

inspection .......................................................................................................... 26

Appendix 2 HIQA’s Risk Escalation process .......................................................... 29




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Section 1: Overview

1.1 Introduction

Under the Health Act 2007, Section 8(1) (c) confers the Health Information and

Quality Authority (HIQA) with statutory responsibility for monitoring the quality and

safety of healthcare among other functions. In light of the ongoing global pandemic

of COVID-19, HIQA has developed a monitoring programme to assess compliance

against the National Standards for the prevention and control of healthcare-

associated infections in acute healthcare services during the COVID-19 pandemic.

The national standards provide a framework for service providers to assess and

improve the service they provide particularly during an outbreak of infection

including COVID-19.

This focused monitoring programme against the National Standards for the

prevention and control of healthcare-associated infections in acute healthcare

services is designed to complement, but run separately from, HIQA’s existing

programmes:

monitoring against National Standards for Infection Prevention and Control in

Community Services (rehabilitation and community inpatient healthcare

services) during the COVID-19 pandemic

regulation of medical exposure of ionising radiation

registration and regulation of designated centres in accordance with Section

41 of the Act.

This guide document should be applied in conjunction with the following:

National Standards for the prevention and control of healthcare-associated

infections in acute healthcare services (2017)

Assessment judgment framework for monitoring compliance against the

National Standards for the prevention and control of healthcare-associated

infections in acute healthcare services (2020)

The Health Act 2007 (as amended).

1.2 Aim of this programme

The aim of this focused inspection programme is to promote improvement in the

management of infection prevention and control. The programme will monitor

compliance with specific national standards for infection prevention and control in




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acute hospitals, with a focus on the ongoing COVID-19 pandemic and its

management in acute hospitals.

1.3 The purpose of this guide

This guide provides information to service providers on the national standards that

will be monitored by inspectors and should also be used by service providers to self-

assess their own service.

1.4 General queries in relation to this programme

General queries or questions in relation to this programme or the information

contained within this guide can be sent by email to [email protected].

Such queries will be referred to a member of the Healthcare Team involved in the

programme for reply. It should be noted, however, that specific queries about an

inspection can only be accepted from the manager in overall charge of the hospital.

mailto:[email protected]




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Section 2: How HIQA will inspect through this monitoring

programme

The following section of this report outlines the specifics of how HIQA will conduct

each inspection and progress to the publication of individual inspection reports under

this programme of monitoring. Further detail of what HIQA will be assessing against

the national standards is outlined in Section 3 of this document.

2.1 Inspection teams

Inspection teams comprise HIQA staff who have been appointed by HIQA as

Authorised Persons under the Health Act 2007, and work within the powers described

in the Act to monitor compliance with standards. Inspectors are obliged to comply

with HIQA’s Code of Conduct for staff, which is available at www.hiqa.ie.

2.2 Before an inspection

HIQA will review key pieces of information relating to the way the service is

organised and operated. Key pieces of information include:

information from previous HIQA inspections

relevant unsolicited information received by HIQA in relation to the service.

2.3 Public health precautions during inspection

Inspectors will take all necessary precautions, in line with public health advice to

reduce risks associated with COVID-19. This will include:

the observation of physical distancing at all times throughout the inspection

the monitoring by HIQA of symptoms of COVID-19 in inspectors, including

checking temperature prior to entering a hospital

a declaration by the inspector to the person with overall responsibility for the

hospital that they have no symptoms of illness or a raised temperature

the observation of good hand hygiene at all times

compliance with respiratory hygiene and cough etiquette by inspectors at all

times

the appropriate use of personal protective equipment in accordance with HSE

guidance and any national recommendations

http://www.hiqa.ie/




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compliance with any additional measures hospitals have in place as

appropriate.

Furthermore, inspectors will be familiar with the most recent guidance and guidelines

from the Health Service Executive (HSE) and the Health Protection Surveillance

Centre (HPSC).

2.4 On-site fieldwork

Inspections may be unannounced (the hospital will not receive any prior

notification of the date of an inspection) or short-term announced (where 48 hours’

notice prior to inspection will be provided). Inspections will generally be performed

within core working hours. At the beginning of the inspection, inspectors will

introduce themselves, outline the purpose and duration of the inspection to the

person with overall responsibility for the hospital.

Information will be gathered by the inspection team through:

speaking with management, staff and patients. Meetings will be held in line

with guidance on physical distancing. Where physical distancing cannot be

maintained, appropriate personal protective equipment will be worn by

inspectors in line with public health guidance

reviewing documents and data to determine if appropriate records are kept

and reflect practice

observing clinical environments.

2.5 The day of inspection

On arrival at the hospital, the inspection team will meet with the person with overall

accountability and responsibility for the hospital, for example, the chief executive

officer or general manager. Hospitals will be asked to nominate a liaison person who

will be responsible for engagement with HIQA during the course of the inspection.




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Table 1. Sample one-day unannounced/announced inspection schedule

During the inspection, inspectors will:

Request access to a secure room (ideally where physical distancing can be

maintained) for the purpose of interviews and documentation review.

Request visitor name badges or door access cards to facilitate movement

throughout the service. These should be made available to the inspection

team as soon as possible following arrival onsite and will be returned at the

end of the inspection.

Ascertain if access to clinical areas are restricted, for example, for health and

safety reasons.

2.6 Documentation, data and information request

HIQA will request documentation, data and information on the day of inspection and

will review the documentation and data provided (Appendix 1).

2.7 Confidentiality

In line with current data protection legislation, HIQA requests that unless specifically

requested to do so, services do not send named patient information or information

Close out meeting

Review of documentation

Clinical areas inspections

Meetings:

1. Infection Prevention and Control Team

2. CEO/ General Manager

3. Clinical Director

Meet with the manager in overall charge

Arrive on site for announced/unannounced inspection




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that could identify an individual patient to HIQA by email or by post. Hard copy

documents provided to inspectors for removal from the service should not contain

data that identifies individual patients.

2.8 Meetings

The inspection team will arrange a time to meet with key personnel. Meetings will be

held with, for example:

infection prevention and control team member or members

the person with overall responsibility for the hospital on the day of inspection

the clinical director

the clinical nurse manager or nurse in charge in the inpatient ward or wards.

The purpose of the meetings is to gather information about:

how the service is led and managed

how risks are identified and managed

how the management team is assured that the service provided is safe and

effective.

2.9 Clinical area inspections

The inspection team will visit inpatient wards or units and gather information in

relation to the management of and oversight arrangements to ensure prevention and

control of infection and outbreak management.

The inspection team will use specific monitoring tools to gather information about

the management and oversight arrangements. Monitoring tools are aligned to the

national standards, HSE standards and guidance, relevant legislation and

recommended best practice guidance. It should be noted that these tools have been

specifically designed for HIQA monitoring purposes only.

2.10 Close-out meeting

When the inspection has been completed, the inspection team will conduct a close-

out meeting with the manager with responsibility for the hospital. The purpose of

this meeting is to provide preliminary findings of the inspection and identify any high

risks which require immediate action and to allow management address such risks.




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2.11 Risk management and escalation

HIQA takes a risk-based approach to monitoring. This approach informs how

frequently HIQA will inspect any individual service. It also informs the nature,

intensity and the type of inspection carried out.

Risk identified by HIQA during this monitoring programme will be escalated to the

manager in overall charge in line with HIQA’s risk management process:

High risks identified during a service inspection which require immediate

mitigation will be brought to the attention of the manager in overall charge

during the inspection. This is to allow them to immediately implement the

actions necessary to mitigate such risks.

Formal written notification of any identified risk arising during this monitoring

programme will be issued to the manager in overall charge by email within

two working days of identifying the risk; with the requirement to formally

report back to HIQA stating how the risk has been mitigated within a further

two working days. (Appendix 2)

In the case of high risks whereby immediate mitigation may not be reasonably

achievable, formal notification of the identified risk will be issued to the

manager in overall charge by email within two working days of identifying the

risk; with the requirement to formally report back to HIQA with an action plan

to reduce and effectively manage the risk within five working days of receiving

correspondence from HIQA. This letter will outline the identified risks and,

where required, will inform the accountable person that another unannounced

monitoring assessment will take place within six weeks of first inspection. This

is to allow them mitigate against identified risks.

2.12 HIQA’s inspection report

An individual report will be generated for each service inspected. Inspection reports

will be published on HIQA’s website at www.hiqa.ie.

Each report will outline HIQA’s findings including areas of good practice and any

identified opportunities for improvement. The report will include risks, if any, that

were identified during the monitoring process and may include correspondence

between HIQA and the manager in overall charge in relation to the management of

such risk. As such, HIQA requests that the hospital does not include individual staff

names in return correspondence.

In 2019, HIQA revised its approach to the receipt of feedback from services on

reports progressing through the drafting process. Under this new and enhanced

http://www.hiqa.ie/




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process, each inspection report goes through three main stages as they are prepared

for publication.

Stage 1 inspection report

A stage 1 inspection report will be issued with a feedback form, by email, to the

manager in overall charge.

Preliminary findings will have been given during the close-out meeting. However,

following review of the stage 1 report the manager in overall charge can return the

feedback form to include any factual accuracy detail along with feedback on receipt

of the stage 1 inspection report.

The manager in overall charge is encouraged to engage with the lead inspector if

deemed necessary and in advance of completion of the formal written

documentation, to discuss specific concerns or queries they may have regarding the

judgments in this stage 1 inspection report. This can be completed by phone and or

email.

To complete the feedback process, and having engaged as necessary via telephone

or email with the lead inspector, if deemed necessary, the manager in overall charge

should formally complete the factual accuracy and feedback form provided with the

draft report, and return this to HIQA within 15 working days of receipt.


On receipt of feedback from the service on a stage 1 report, HIQA will consider the

feedback in the context of evidence gathered on inspection. Consequently, a stage 2

inspection report will be produced which will include any required amendments made

by the inspector resulting from the feedback process. This stage 2 report will then be

again issued to the service for review.

If the manager in overall charge believes that the judgment or judgments contained

in the stage 2 inspection report are not based on the evidence made available to

inspectors at the time of the inspection, or if they believe that the judgment(s) are

disproportionate to the evidence reviewed, they may decide to make a formal

submission to HIQA to challenge a regulatory judgment or judgments contained in

the stage 2 report.

Should a manager in overall charge decide to make a submission, this must be made

within 10 working days of receipt of the stage 2 report. The process for

making a formal submission is detailed below. Should 10 days elapse without receipt

of submission on a regulatory judgment, reports will proceed to stage 3 and

publication as outlined below.




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A stage 3 inspection report is issued to the manager in overall charge prior to

publication. The stage 3 report is the version of the report that will be published and,

if a submission has been received, the stage 3 inspection report will have taken into

consideration any decisions of the Submissions Decision Panel.

The stage 3 inspection report will be sent to the manager in overall charge five

working days before publication. A copy of the draft report will also be sent to

other relevant personnel as formally agreed with the HSE and Department of Health.

HIQA’s revised submission policy 2019

The manager in overall charge can make a formal submission if they believe that the

judgment(s) contained in the stage 2 inspection report are not based on the

evidence made available to inspectors at the time of the inspection or the

judgment(s) are disproportionate to the evidence reviewed.

As part of this process, the manager in overall charge may formally submit

comments, evidence or descriptors of circumstances that supports their case.

A service wishing to make a submission on a regulatory judgment must first engage

in the feedback process with the lead inspector as described in the section ‘Stage 1

inspection report’ above.

Further information on HIQA’s submissions procedure and how to make a submission

can be found on the HIQA website (www.hiqa.ie).

2.13 Freedom of Information

HIQA is subject to the Freedom of Information Acts and the statutory Code of

Practice regarding Freedom of Information.

http://www.hiqa.ie/

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Section 3: National Standards

The National Standards for the prevention and control of healthcare-associated

infections in acute healthcare services (2017) were developed using an established

framework for the development of all national standards.

Figure 1 illustrates the eight themes under which these standards are presented. The

four themes on the upper half of the circle relate to quality and safety in a service,

while the four on the lower portion of the circle relate to the key areas of a service’s

capacity and capability. The National Standards for the prevention and control of

healthcare-associated infections in acute healthcare services (2017) can be accessed

on the HIQA website - www.hiqa.ie

Figure 1 Themes in the National Standards for the prevention and control

of healthcare-associated infections in acute healthcare services

The national standards are organised into two dimensions:

1. Quality and safety

2. Capacity and capability

http://www.hiqa.ie/




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3.1 Quality and safety

The four themes of quality and safety are:

Person-centred Care and Support — how acute healthcare services

communicate with patients to ensure they are well informed, involved and

supported in the prevention, control and management of healthcare-associated

infections throughout their care pathway.

Effective Care and Support — how acute healthcare services effectively plan,

organise and manage infection prevention and control efforts to achieve best

possible outcomes for patients.

Safe Care and Support — how acute healthcare services support a culture of

patient safety through effective management of risks and healthcare-associated

infection incidents and by promoting change and improvement in infection

prevention and control practices.

Better Health and Wellbeing — how acute healthcare services work in

partnership with patients, families and visitors to promote and enable safe infection

prevention and control practices.

3.2 Capacity and capability

Delivering improvements within these safety and quality themes depends on

service providers having capacity and capability in the following four key areas:

Leadership, Governance and Management — the arrangements put in place

by a service for accountability, strategic decision-making and performance

assurance, underpinned by integrated communication and reporting networks

among staff.

Workforce — how acute healthcare services ensure enough staff are available at

the right time with the right skills and expertise to meet the service’s infection

prevention and control needs.

Use of Resources — how acute hospitals plan, manage and prioritise their

resources to meet the service’s infection prevention and control needs.

Use of Information — how acute healthcare services ensure the integration,

availability and protection of all information sources necessary to provide safe and

effective infection prevention and control practices.

3.3 Standards for review under this monitoring programme

This section of the guide will outline the six key National Standards for the

prevention and control of healthcare-associated infections in acute healthcare

services (2017) selected for review for this inspection programme. Only those

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national standards which are relevant to the focus of the inspection will be included

under the respective theme.

The lines of enquiry for this monitoring programme of infection prevention and

control in acute hospitals will focus on six specific national standards within four of

the eight themes of the standards, spanning both the capacity and capability and

quality and safety dimensions. Acute hospitals should always aim to comply with all

the national standards for infection prevention and control.

Guidance under each individual standard is presented in the following section. Each

standard will describe what a service meeting this standard looks like.

These are set out in more detail in the following sections of this document.

Capacity and capability dimension

Theme: Leadership Governance and Management

Standard 5.3 Service providers have formalised governance

arrangements in place to ensure the delivery of safe and effective

infection prevention and control across the service.

Theme: Workforce

Standard 6.1. Service providers plan, organise and manage their

workforce to meet the services’ infection prevention and control needs.

Quality and safety dimension

Theme: Effective care and support

Standard 2.6: Healthcare is provided in a clean and safe physical

environment that minimises the risk of transmitting a healthcare-

associated infection.

Standard 2.7: Equipment is cleaned and maintained to minimise the risk

of transmitting a healthcare–associated infection

Theme: Safe care and support

Standard 3.1: Service providers integrate risk management practices

into daily work routine to improve the prevention and control of

healthcare-associated infections.

Standard 3.8: Services have a system in place to manage and

control infection outbreaks in a timely and effective manner.




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Section 4: Guidance for assessment judgment framework

HIQA is responsible for assessing whether the service provider is in compliance with

the national standards under Section 8 1 (c) of the Health Act 2007 as amended.

In order to carry out its functions as required by the Health Act 2007 as amended,

HIQA has adopted a common Authority Monitoring Approach (AMA). All HIQA staff

involved in the regulation of services or the monitoring of services against standards

are required to use this approach and any associated policies, procedures and

protocols. HIQA’s monitoring approach does not replace professional judgment.

Instead, it gives a framework for staff to use professional judgment and supports

them to do this. The aim of AMA is to ensure:

a consistent and timely assessment and monitoring of compliance with

regulations and standards

a responsive and consistent approach to regulation and assessment of risk

within acute hospitals

contribute to the improvement of the service being inspected through

application of the inspection process.

In order to improve the quality and safety of healthcare services, service providers

are encouraged to continually seek improvements in the services they provide to

patients admitted to these hospitals.

4.1 Assessment judgment framework

The inspection team will use an assessment judgment framework to guide them in

assessing and judging a service’s compliance with the national standards. It sets out

the lines of enquiry to be explored by inspectors in order to assess compliance with

the standards being monitored or assessed. Once an inspector has gathered and

reviewed evidence from a service, they will make a judgment on how the service

performed. The following judgment descriptors will be used:

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Compliant Substantially compliant

Partially compliant

Non-compliant

A judgment of compliant means that on the basis of this inspection, the service is in compliance with the relevant national standards.

A judgment of substantially compliant means that the service met most of the requirements of the national standards but some action is required to be fully compliant.

A judgment of partially compliant means that the service met some of the requirements of the relevant national standard while other requirements were not met. These deficiencies, while not currently presenting significant risks, may present moderate risks which could lead to significant risks for patients over time if not addressed.

A judgment of non-compliant means that this inspection of the service has identified one or more findings which indicate that the relevant standard has not been met, and that this deficiency is such that it represents a significant risk to patients.

Capacity and capability

This section focuses on the overall delivery of the service and how the provider is

assured that a quality, safe and effective service is provided to people admitted to

acute hospitals.

It includes how the service provider:

is assured that there are effective governance structures and oversight

arrangements in place for clear accountability, decision-making, risk

management and performance assurance. This is underpinned by effective

communication among staff. This includes how responsibility and

accountability for infection prevention and control is integrated at all levels of

the service.

plans, manages and organises their workforce to ensure enough staff are

available at the right time with the right skills and expertise to meet the

service’s infection prevention and control needs.

ensures that the necessary resources are in place to to meet the service’s

infection prevention and control needs.




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For the purpose of this inspection, inspections will monitor compliance in relation to

the following themes and standards.

Theme: Leadership Governance and Management

Standard 5.3: Service providers have formalised governance arrangements in

place to ensure the delivery of safe and effective infection prevention and control

across the service.

What a service meeting this standard looks like:

Corporate and clinical governance arrangements that outline clear roles,

responsibilities and reporting-up-and-down processes for the prevention and

control of healthcare-associated infections at all levels of staff throughout the

service are in place.

Governance arrangements ensure that effective infection prevention and control

and antimicrobial stewardship programmes are in place, with the required

resources to implement them.

Corporate and clinical governance arrangements are integrated to ensure that

those staff with specialist expertise, who can evaluate and advise on the

management of infection prevention and control risk, report directly to those with

operational management responsibility and authority to actively address these

risks.

Services have developed and operate pathways to treat both patients with COVID

and without COVID simultaneously.

A mechanism is in place to ensure that the indicators selected to assess the

service’s performance in the prevention and control of healthcare-associated

infections and antimicrobial stewardship provide an accurate level of assurance.

The people involved in the governance of the service have the capacity, skills and

competencies necessary to effectively meet the requirements of their leadership

and managerial roles.

Regular safety walk-rounds by senior management, including meeting with staff,

listening to their insights on infection prevention and control, identifying examples

of good practice and areas for improvement, with documentation of the

conclusions and actions to be taken.

Clinical leaders ensure oversight and coordination of infection prevention and

control activities at the point of care.

Arrangements are in place for the timely sharing of information about healthcare-

associated infection incidents and outbreaks within the service.

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Local governance arrangements are in place to help share resources between

hospitals where appropriate.

Theme 6: Workforce

Standard 6.1.

Service providers plan, organise and manage their workforce to meet the

services’ infection prevention and control needs.

What a service meeting this standard looks like

Staffing, including infection prevention and control personnel, is maintained at levels that are recognised as appropriate by international evidence to safely meet the service’s infection prevention and control needs and activities, including appropriate staffing levels for out-of-hours arrangements.

Each hospital has a multidisciplinary infection prevention and control committee, a drugs and therapeutics committee and an antimicrobial stewardship subcommittee as deemed appropriate by the hospital, with established formal linkages with other relevant committees within the service.

Infection prevention and control and antimicrobial stewardship teams have core members and can request additional members when required. The infection prevention and control and antimicrobial stewardship workforce is organised and managed to work in multidisciplinary teams.

Patient care areas have appropriate numbers of staff to ensure infection prevention and control needs are met.

The workforce plan includes a training needs analysis for all grades of staff in order to deliver safe and effective infection prevention and control practices.

Service providers implement workforce contingency and succession planning for all staff, including trained specialist staff in infection prevention and control, to seamlessly continue to deliver a safe, effective, and sustainable service as staff leave or transfer to other parts of the service.

Regular review and evaluation of the management of the workforce, and the service’s response to changes in workload and the resources available, to ensure the consistent delivery of safe and effective infection prevention and control in the service, are undertaken.

Workload distribution is regularly reviewed with protected time being allocated to staff for surveillance, monitoring or quality improvement activities.

Arrangements are in place to support sharing of expertise and resources across the relevant staff disciplines within the service.




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Quality and safety

The focus of this section is about how hospitals ensure that infection prevention and

control outbreaks, including of COVID-19, are managed to protect people using the

healthcare service.

This includes how the services identify any work practice, equipment and

environmental risks and put in place protective measures to address the risk,

particularly during a pandemic.

It also focuses on how these services ensure that staff adhere to infection prevention

control best practice and antimicrobial stewardship to achieve best possible

outcomes for people during the ongoing COVID-19 pandemic.

For the purpose of this inspection, inspections will monitor compliance in relation to

the following themes and standards:

Theme 2: Effective Care and Support

Standard 2.6: Healthcare is provided in a clean and safe physical environment

that minimises the risk of transmitting a healthcare-associated infection.


Design and Layout: A physical healthcare environment is planned, designed, developed and maintained to facilitate effective cleaning and compliance with infection prevention and control best practice. The size, complexity and specialities of the service are considered when planning the design and layout of the facility. Patient accommodation is planned and managed in a way that minimises the spread of healthcare-associated infections and maintains the patient’s dignity and privacy in line with national guidelines. Patient pathways allow for physical distancing in emergency departments, theatre and treatment rooms, inpatient bedrooms, examination room layouts, diagnostics and x-ray and all waiting areas. Physical environmental hygiene and safety: Arrangements and documented specifications are in place for cleaning and disinfection of the physical environment, in line with best practice guidance. This includes clearly defined responsibilities for staff involved in cleaning. Arrangements and specifications are in place for linen and laundry management

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including cleaning, decontamination, collection, transport and storage, in line with best practice. Arrangements and specifications are in place for the management of reusable cleaning textiles in line with best practice. Arrangements and specifications are in place for waste management including arrangements for safe handling, segregation, storage, transportation and disposal, in line with national waste management guidelines and legislation. Formalised arrangements are in place to monitor and inspect the physical infrastructure, maintenance and environmental cleanliness to ensure the service complies with national standards. A quality improvement plan is implemented if any areas for improvement are identified.

Theme 2: Effective Care and Support

Standard 2.7

Equipment is cleaned and maintained to minimise the risk of transmitting a

healthcare-associated infection.


All equipment is safely and effectively cleaned, decontaminated, maintained and managed in accordance with legislation, the manufacturer’s instructions, national medical devices and equipment standards policy, standards and best practice guidance.

Arrangements and documented specifications are in place for cleaning, disinfecting and sterilising equipment. This includes clearly defined responsibilities for staff.

Equipment designated ‘single use’ is not re-used under any circumstances.

Dedicated equipment in rooms designated for isolation is appropriately decontaminated prior to use on another patient.

Reusable non-invasive equipment or medical devices is decontaminated, as appropriate for the level of infection risk, between each patient use.

There are designated storage areas for large items of equipment such as beds, mattresses, hoists, wheelchairs and trolleys which are clean but not in use.

Regular monitoring and inspection of the cleanliness of equipment is undertaken. Action is taken to address any areas identified for improvement.




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Theme 3: Safe Care and Support

Standard 3.1. Service providers integrate risk management practices into daily

work routine to improve the prevention and control of healthcare-associated

infections.


Systems for the proactive identification, assessment, mitigation, monitoring and reporting of infection risks are in place and in line with the service’s risk management policy.

The service regularly reviews any significant infection risks to patients by conducting service-wide infection prevention and control risk assessments. This includes reviews during periods of service reorganisation or when demand and resources change such as overcrowding, infection outbreaks and understaffing. Arrangements are in place to minimise the impact on infection prevention and control activities.

Any risks that cannot be adequately mitigated at the point of care are escalated to the next level of management for action, and to the national service provider if necessary.

Staff are trained and assisted to integrate risk management techniques into their daily tasks and duties that involve infection prevention and control. This includes assessing patients for risk of infection, assessing the environment for risk of infection and implementing standard precautions and transmission-based precautions, in line with best practice.

Staff adhere to the service’s infection prevention and control policies and procedures, guidelines and standards in order to effectively anticipate and mitigate healthcare-associated infections and antimicrobial resistance risks.

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Theme 3: Safe Care and Support

Standard 3.8. Services have a system in place to manage and control infection

outbreaks in a timely and effective manner.


Arrangements are in place to assist staff in promptly recognising and responding to any symptoms or signs in patients which are suggestive of an outbreak. The infection prevention and control team is informed of any confirmed, probable or suspected cases.

A surveillance system that can detect and respond to any emerging critical data that meet the case definition criteria for an outbreak is in place.

Up-to-date outbreak management policies and procedures are available that outline staffing arrangements, leadership roles and responsibilities, communication strategy, outbreak control measures and surveillance activities during any outbreaks.

Any suspected or confirmed outbreaks are promptly notified to the medical officer of health in the Departments of Public Health, in line with legislation.

Everyone who needs to know about the status of an outbreak within and between healthcare services is informed and updated. Staff are supported during an outbreak.

A mechanism is in place for an out-of-hours response to an outbreak that outlines staffing, reporting and patient placement arrangements.

A multidisciplinary outbreak control team is convened in the event of a suspected or confirmed outbreak in line with best practice that is chaired by a designated member of the senior management team.

An outbreak management plan is implemented that outlines the steps for managing, containing and monitoring the outbreak. An escalation plan is put into place if the situation deteriorates.

The outbreak is immediately investigated by the infection prevention and control team, supported by senior management, risk management and patient safety and quality specialists, which includes identifying the responsible micro-organism, the route of transmission and groups of patients at risk.

A report outlining the outcome of the investigation of the outbreak is presented to senior management within and between all healthcare services, with feedback of outbreak control learning points provided to staff to identify any areas for improvement.




Page 25 of 30

Bibliography

Health Act 2007. Dublin: The Stationery Office; 2007. Available online from:

http://www.irishstatutebook.ie/eli/2007/act/23/enacted/en/print

Health Information and Quality Authority. National Standards for infection prevention

and control of healthcare-associated infections in acute healthcare services. Dublin:

Health Information and Quality Authority; 2017. [Online]. Available online from:

https://www.hiqa.ie/reports-and-publications/standard/2017-national-standards-

prevention-and-control-healthcare

Health Information and Quality Authority. Enhanced Authority Monitoring Approach

Guidance. Dublin: Health Information and Quality Authority; 2017. [Online]. Available

online from: https://www.hiqa.ie/sites/default/files/2018-02/Enhanced-Authority-

Monitoring-Approach_Guidance.pdf

Health Service Executive Health Protection Surveillance Centre. Acute Hospital

Infection Prevention and Control Precautions for Possible or Confirmed COVID-19 in

a Pandemic Setting. Dublin: Health Service Executive Health Protection Surveillance

Centre., 2020 Available online from:https://www.hpsc.ie/a-

z/respiratory/coronavirus/novelcoronavirus/guidance/infectionpreventionandcontrolgu

idance/Infection%20Prevention%20and%20Control%20Precautions%20for%20Acut

e%20Settings%20-COVID-19.pdf

http://www.irishstatutebook.ie/eli/2007/act/23/enacted/en/print

https://www.hiqa.ie/reports-and-publications/standard/2017-national-standards-prevention-and-control-healthcare

https://www.hiqa.ie/reports-and-publications/standard/2017-national-standards-prevention-and-control-healthcare

https://www.hiqa.ie/sites/default/files/2018-02/Enhanced-Authority-Monitoring-Approach_Guidance.pdf

https://www.hiqa.ie/sites/default/files/2018-02/Enhanced-Authority-Monitoring-Approach_Guidance.pdf

https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/guidance/infectionpreventionandcontrolguidance/Infection%20Prevention%20and%20Control%20Precautions%20for%20Acute%20Settings%20-COVID-19.pdf




Page 26 of 30

Appendix 1 Sample documentation and data request for review

on the day of inspection

Data request – for review on day of inspection

1 Total number of hospital beds

2 Total number of in-patients today

3 Total number of single rooms in the hospital

How many of these rooms have an ensuite toilet facilities?

4 Number of inpatients for which single room isolation is indicated today

5 Number of inpatients isolated in single rooms today

6 Location of in-patients where single room isolation is indicated and who are not isolated in single rooms

7 Number of suspected or confirmed cases of COVID-19 inpatients/outbreak line listing if relevant

8 Number of suspected or confirmed cases of COVID-19 staff/outbreak line listing if relevant

9 Number of staff that have tested positive for COVID-19

to date

10 Are all confirmed cases of COVID-19 inpatients in single rooms or cohorted appropriately

11 Number of COVID-19 cohorted isolation areas in place

12 Any other outbreak of infection in hospital today

13 Number of neutral or negative pressure isolation rooms




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On-site documentation and data request

Infection prevention & control documentation and data request

Infection Prevention and Control team organogram (and email to HIQA)

1. Infection Prevention and Control risk register

2. List of Infection prevention and control-related risks only on the hospital risk register risks and existing controls on the current hospital risk register (these will be reviewed and discussed during management meetings)

Policy or procedure or Guideline Yes/ No Date

written

Review

date

Ratified by

Outbreak management

policy/guidelines

COVID 19 preparedness/ contingency

plans

Hospital policy on standard and

transmission based precautions or

equivalent

Admission and discharge policy during

an outbreak (inclusive of streaming of

patients on admission for

scheduled/unscheduled care)

Interfacility transfer form

IPC patient placement policy

Occupational health guidance/policy in

relation to IPC – COVID-19

Page 28 of 30

Sample Documentation Email Request

The following documents are to be emailed to HIQA through the office of the

CEO/General Manager to the email address: [email protected]. Documents

emailed to HIQA by email must not contain named patient information.

Email Request

1 COMMITTEES – Terms of reference (TOR)

Infection Prevention and Control Committee: TOR and list of members by discipline

Outbreak Control team membership/TOR

2 MEETING MINUTES

Minutes/agenda of Safety and Quality Executive Steering Group for last 3 meetings

Minutes of infection prevention and control committee meetings for the last 3 meetings and any reports

circulated at these meetings.

Minutes/agenda of COVID-19 Outbreak Control team (check frequency of meetings)

Minutes of Hospital Group IPC meetings 2020

3 REPORTS

Infection prevention and control annual report (latest report) and programme plan

Microbiology surveillance report for the last quarter

Antimicrobial stewardship annual report (latest report)

Hospital hygiene audit report (last 12 months)- 1 page trended report.

Patient equipment hygiene audit report results (last 12 months)1 page trended report.

IPC incidents – tracked and trended report (last 12 months if available)

Written reports of any outbreaks or clusters of infection in the hospital in the last 12 months

4 Plans (Quality Improvement Plans)

QIP developed following previous HIQA PCHCAI inspection – updated version

5 Data

% of staff trained in hand hygiene in the last two years – presented by staff discipline

Infection Prevention and Control: Trending and overall % completed staff training records in relation to

outbreak management, TBP/SBP (clinical and non-clinical staff, agency, bank staff)

PLEASE DO NOT RETURN LISTS OF NAMES WHO HAVE COMPLETED TRAINING.

mailto:[email protected]

Guide to HIQA’s targeted monitoring programme against the National Standards for the prevention and control of healthcare-associated infections in acute healthcare services

during the COVID-19 pandemic


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Appendix 2 HIQA’s Risk Escalation process

Page 30 of 30

Published by the Health Information and Quality Authority

(HIQA).

For further information please contact:


George’s Court

George’s Lane

Smithfield

Dublin 7

D07 E98Y

+353 (0)1 814 7400

[email protected]

www.hiqa.ie

© Health Information and Quality Authority 2020