1. Infection prevention and control
Health Establishments Performance

2. Structure of the National Core Standards

3. General Performance in infection control

4. Performance by Province

5. Performance by facility type by Province

6. Standard outcome Performance by Province

7. An Infection Prevention and Control Programme to reduce healthcare associated infections is implemented

8. Universal precautions are applied to prevent health care associated infections

9. Specific precautions are taken to reduce or prevent respiratory infections

10. Strict infection control practices are observed in the designated feed preparation areas to prevent infection

11. poor performance at criteria level Nationaly (below 50% in all provinces)

12. Effective hand washing limits the spread of healthcare associated infections

13. An infection prevention and control policy is available which outlines the health establishments approach to the management of healthcare associated infections

14. The organization provides education on healthcare associated infection control practices to the staff / patients and as appropriate family and other caregivers

15. Policy and procedures related to Universal precautions to prevent healthcare associated infections are actively implemented and applied in all clinical areas of the health establishment

16. GOOD performance at criteria level (NATIONAL AVERAGE ABOVE 80%)

17. A healthcare professional with appropriate qualifications or experience oversees infection control in the health establishment

18. Sharps are safely managed and disposed

19. Equipment used by infected patients is correctly and safely disinfected

20. Ventilation systems in the patient care units reduce the transmission risk of respiratory infections

21. The appropriate transportation of patients with respiratory infections will reduce the risk of infection

22. Performance on Vital and Extreme measures by Province

23. Performance on Vital and Extreme measures by Province

24. Thank you

25. Step 4: Compliance Status
Score
NG & E (FA’s)
Clinical outcomes*
Status
Grade
> 80%
<20%
Excellent
Compliant A
70 – 79% %
Good
Compliant with conditions B
60 – 69%
31 – 40%
Average
Limited compliance C
50 – 59%
41 – 50%
Fair
Limited compliance with serious concerns D
40 – 49%
51 – 60%
Poor
Non-compliant E
< 40%
> 60%
Very poor
Seriously non-compliant F
*Can also be defined in Std Deviations from expected threshold or benchmark and therefore can be substantiated
#Depends on how many of the key CF are poor and cannot be substantiated 24

26. Step 5: Follow up frequency
Score
NG & E (FA’s)
Clinical outcomes*
Status
Grade
Improvement capacity#
Follow up mechanism
Inspection frequency
> 80%
<20%
Excellent
Compliant A
Regular routine reporting
4 yrly inspections
70 – 79% %
Good
Compliant with conditions B
Self reported corrections, regular routine reporting
adhoc inspections
60 – 69%
31 – 40%
Average
Limited compliance C
Improvement and self reported review
specific reinspection
50 – 59%
41 – 50%
Fair
Limited compliance with serious concerns D
Improvement and specific reporting
Specific Re-inspection
40 – 49%
51 – 60%
Poor
Non-compliant E
Urgent intervention and complete re-inspection
Complete re-inspection
< 40%
> 60%
Very poor
Seriously non-compliant F
Urgent intensive intervention with disciplinary steps
Enforcement
*Can also be defined in Std Deviations from expected threshold or benchmark and therefore can be substantiated
#Depends on how many of the key CF are poor and cannot be substantiated 25