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Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
Guide: Monitoring Programme for
unannounced inspections undertaken
against the National Standards for the
Prevention and Control of Healthcare
Associated Infections
28 May 2015
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Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
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Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
Contents
About the Health Information and Quality Authority ......................................................... 4
1. Purpose of this guide ................................................................................................. 5
2. Background............................................................................................................... 6
2.1 The Role of the Health Information and Quality Authority ........................................ 6
2.2 Prevention of Healthcare Associated Infection - A Key Patient Safety Intervention ...... 6
2.3 The role of standards and continuous monitoring in improving quality and safety in
healthcare .................................................................................................................... 9
3. The monitoring programme……………………………………………………………………………………..10
3.1 The programme aims and objectives……………………………………………………………………10
3.2 The monitoring approach for unannounced inspections…………………………………………12
3.3 Authorised Persons…………………………………………………………………………………………….12
3.4 Unannounced inspections……………………………………………………………………………………13
3.4.1 The inspection………………………………………………………………………………………………13
3.4.2 Before the inspection……………………………………………………………………………………..14
3.4.3 During the inspection……………………………………………………………………………………..14
3.4.4 Observation, and discussion with staff and patients…………………………………………..15
3.4.5 Documentation review……………………………………………………………………………………17
4. After inspection………………………………………………………………………………………………………19
4.1 Risk identification, assessment and notification ................................................... 20
4.2 Findings…………………………………………………………………………………………………………..20
5. The Report............................................................................................................. .21
5.1 Publication of reports ......................................................................................... 22
6. Expected hospital response …………………………………………………………………………………..23
7. Continuous monitoring post inspection ...................................................................... 24
Appendix 1 – Hygiene Observation Tool ........................................................................ 25
Appendix 2 – Risk matrix ............................................................................................. 38
Appendix 3 – Risk escalation process map ................................................................... ..40
Appendix 4 - References……………………………………………………………………………………………..42
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Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
About the Health Information and Quality Authority
The Health Information and Quality Authority (HIQA) is the independent Authority
established to drive high quality and safe care for people using our health and social
care services. HIQA’s role is to promote sustainable improvements, safeguard people
using health and social care services, support informed decisions on how services are
delivered, and promote person-centred care for the benefit of the public.
The Authority’s mandate to date extends across the quality and safety of the public,
private (within its social care function) and voluntary sectors. Reporting to the
Minister for Health and the Minister for Children and Youth Affairs, the Health
Information and Quality Authority has statutory responsibility for:

Setting Standards for Health and Social Services – Developing personcentred standards, based on evidence and best international practice, for those
health and social care services in Ireland that by law are required to be regulated
by the Authority.

Supporting Improvement – Supporting health and social care services to
implement standards by providing education in quality improvement tools and
methodologies.

Social Services Inspectorate – Registering and inspecting residential centres
for dependent people and inspecting children detention schools, foster care
services and child protection services.

Monitoring Healthcare Quality and Safety – Monitoring the quality and
safety of health and personal social care services and investigating as necessary
serious concerns about the health and welfare of people who use these services.

Health Technology Assessment – Ensuring the best outcome for people who
use our health services and best use of resources by evaluating the clinical and
cost effectiveness of drugs, equipment, diagnostic techniques and health
promotion activities.

Health Information – Advising on the efficient and secure collection and
sharing of health information, evaluating information resources and publishing
information about the delivery and performance of Ireland’s health and social
care services.
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Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
1.
Purpose of this guide
This is a guide to the Health Information and Quality Authority’s (the Authority)
programme of monitoring hospital’s compliance with the National Standards for the
Prevention and Control of Healthcare Associated Infections. This guide explains the
approach that the Authority takes when monitoring the compliance of acute hospitals
with these Standards1. It refers to unannounced inspections only.
Section 2 of this document provides background information including the role of the
Authority, quality and safety in healthcare and the role of standards and continuous
monitoring in improving quality and safety in healthcare.
Section 3 provides details on the Authority’s monitoring programme for unannounced
inspection against Infection Prevention and Control Standards. This includes the
programme aims and objectives, and monitoring approach.
Section 4 outlines the Authority’s risk identification, assessment and notification
process for unannounced inspections.
Section 5 outlines the Authority’s reporting process for unannounced inspections.
Section 6 outlines the response expected from hospitals on receipt of inspection
report findings.
Section 7 outlines the Authority’s continuous monitoring approach post-inspection.
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Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
2.
2.1
Background
The Role of the Health Information and Quality Authority
The Health Information and Quality Authority (the Authority) was established in 2007
to promote safety and quality in the provision of health and personal social services
for the benefit of the health and welfare of the public.
Under section 8(1)(b) of the Health Act 2007, the Authority has, among other things,
the function of setting standards on safety and quality in relation to services provided
by the Health Service Executive (HSE) or a service provider in accordance with the
Health Acts 1947 to 2007.
Under section 8(1)(c) of the Health Act 2007, the Authority also has the function to
monitor compliance with standards and to advise the Minister for Health and the HSE
as to the level of compliance of the HSE and service providers with the standards.
2.2
The Prevention of Healthcare Associated Infection – A Key Patient
Safety Intervention
Many countries, including Ireland, have identified the need to further advance the
quality and safety of services for patients through a process of continuous
improvement. It is recognised internationally that the setting and implementation of
standards, and monitoring hospital’s compliance with them are important levers in
driving improvements in quality and safety in healthcare.
The World Health Organization (WHO) defines a Healthcare Associated Infection as
“An infection occurring in a patient during the process of care in a hospital or other
healthcare facility which was not present or incubating at the time of admission. This
includes infections acquired in the hospital, but appearing after discharge, and also
occupational infections among staff of the facility”2.
Every patient has the right to receive high quality healthcare in a safe environment
without acquiring a preventable Healthcare Associated Infection or multidrugresistant organism such as Meticillin-Resistant Staphylococcus aureus (MRSA), or
multidrug-resistant Gram-negative organisms such as multidrug-resistant Klebsiella
pneumoniae. However, Healthcare Associated Infections are a common adverse
event for patients. A national survey in Irish hospitals in 2012 revealed that just over
1 in 20 (5.2%) patients in hospital on the day of survey had a Healthcare Associated
Infection3. At their extreme, Healthcare Associated Infections can result in patient
mortality. More often they result in serious illness, prolonged hospital stays or longterm disability. Healthcare Associated Infections result in a high personal impact for
patients, their families, and the health service at large. Healthcare Associated
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Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
Infections impact on the ability of hospitals to deliver services as they require the
reallocation of scarce resources to deal with the consequences of infection. They
therefore also generate a significant additional financial burden for the healthcare
system.
Healthcare Associated Infections are not inevitable consequences of healthcare.
International evidence indicates that Healthcare Associated Infections can be both
prevented and reduced by up to 50% or more2,4. Every healthcare provider must
recognise that the prevention and control of infection is an essential element of their
corporate and clinical governance responsibility in delivering safe, effective and
person centred care to patients. In doing so, healthcare providers must act to embed
infection prevention and control practice in their organisation to protect patients
against the risk of infection. As part of its continued approach to monitoring against
the National Standards for the Prevention and Control of Healthcare Associated
Infection, the Authority will focus its monitoring approach in hospitals to determine
compliance with hand hygiene best practice, environmental hygiene performance,
and effectiveness in the implementation of infection prevention care bundles; three
such measures proven to reduce Healthcare Associated Infection risk. While
monitoring will predominately focus on these areas, other elements of the Standards
will also be incorporated if needed, as identified on the day on inspection.
Education and training of healthcare staff on Infection Prevention and Control
practices is fundamental to the prevention and control of healthcare associated
infections and the transmission of multidrug resistant organisms. Healthcare staff
should be equipped with the knowledge, skills and competencies to enable correct
decision making and evidence-based practice. Infection Prevention and Control
education programmes should be developed using a framework that defines the core
knowledge and skills required for each staff group which is determined by the degree
of contact and care with patients.5 The Authority will focus on the education and
training of staff on Infection Prevention and Control as part of its monitoring
approach to determine compliance with the Standards.
In recent times, the Authority has predominantly focused on hospital performance
with respect to hand hygiene and environmental hygiene as part of its inspection
programme against the National Standards for the Prevention and Control of
Healthcare Associated Infection. Both hand hygiene and environmental hygiene are
key standard precautions for preventing infection in hospitals and other acute care
settings6. A healthcare environment that is clean and well maintained can not only
reduce the risk of infection for patients, but also acts to instill confidence in patients
and visitors in the wider provision of services by the organisation7. Conversely, poor
environmental hygiene performance may pose both a clinical and confidence risk.
Hand hygiene is internationally recognised as the most important and effective way
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Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
of reducing and preventing Healthcare Associated Infections. Improvement in hand
hygiene performance has been associated with reduced infection related morbidity
and mortality experienced by patients.6,8 Hand hygiene is also an essential
component of infection prevention care bundles.
Infection prevention care bundles are internationally recognised as a structured
collection of evidence-based best practice interventions that when performed
collectively, reliably and continuously result in measurably better outcomes for
patients. Care bundles to reduce the risk of different types of infection have been
introduced across many health services over the past number of years, and indeed
there have been a number of Irish guideline documents published over recent years
which have recommended their introduction across the Irish health system.9-12
The use of invasive medical devices such as intravascular and urinary catheters plays
an essential role in patient care. However, invasive medical devices can predispose
patients to infection as the device can enable microorganisms to bypass the patient’s
usual protective mechanisms by acting as a point of entry into the blood stream or
urinary tract.9
Intravascular catheter related blood stream infections may be commonly identified,
are costly to treat and can potentially cause serious illness or patient mortality.13
Such infections are a potential dangerous complication of healthcare. However they
need not be an inevitable consequence of healthcare provision. In some instances,
the routine application of evidence based interventions during insertion, care or
removal of catheters can significantly reduce the chance of an infection. For
example, in the case of central vascular catheter associated infection in intensive
care units, a statewide study carried out in a number of Michigan hospitals (the
Keystone ICU project) set out to identify the potential benefit of the routine
introduction of a “bundle” of evidence based measures to reduce infection associated
with central vascular catheter insertion and care, as part of a collective improvement
initiative.14 This programme showed that the median rate of catheter related blood
stream infections associated with central vascular catheters decreased from 2.7 per
1,000 patients to zero within three months of project commencement, and decreased
by 66% in total during the first 18 months of the initiative. The benefit from the
intervention was sustained after 18 months and had a potential to significantly
reduce morbidity and costs. Other healthcare systems have subsequently translated
the findings of this project to their own setting, with similar positive results.
Further infection prevention care bundles have likewise been developed, and have
been integrated into relevant Irish national guidelines in areas ranging from central
and peripheral vascular catheter line insertion and care, to urinary catheter insertion
and care, surgical site infection prevention, and ventilator associated pneumonia
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Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
prevention.9-12 Their routine adaptation into practice requires a coordinated hospital
approach. It is essential that invasive medical devices which have the potential to
cause infection are managed in line with evidence-based best practice to ensure that,
where possible, related infections are prevented and reduced. The uniform
implementation of invasive medical device infection prevention care bundles are
proven to prevent infection associated with their use, and Irish hospitals are
expected to have them embedded in practice to reduce infection rates and protect
patients.
2.3
The role of standards and continuous monitoring in improving
quality and safety in healthcare
The National Standards for the Prevention and Control of Healthcare Associated
Infections, which are available on the Authority’s website www.hiqa.ie, should be
applied across the Irish health and social care system. The aim of these Standards is
to provide a framework for health and social care providers to prevent or minimise
the occurrence of Healthcare Associated Infections. These Standards are designed to
promote an environment that maximises safety, quality and accountability in health
and social care services. They aim to promote a culture of responsibility and
accountability among all staff involved in the management and delivery of health and
social care services.
The National Standards for the Prevention and Control of Healthcare Associated
Infection are comprised of 12 Standards. These Standards were produced by the
Authority with the assistance of an external expert advisory group, and are designed
to encompass all of the key elements that a Healthcare provider should have in place
to protect patients against the risk of Healthcare Associated Infection. These
Standards include; a focus on hospital leadership, governance and management, the
availability of appropriate resources, and technical standards related to
environmental hygiene, hand hygiene, outbreak management, surveillance and
antimicrobial stewardship (best usage of antibiotics).
International experience has demonstrated that the implementation of evidencebased standards in healthcare settings, together with continuous monitoring of
compliance with these standards is a key quality and safety improvement measure. It
is the role of each hospital to assure itself, its patients and the public that it is
providing safe high quality care by demonstrating that they are meeting the National
Standards for the Prevention and Control of Healthcare Associated Infection at all
times. The Authority, through its monitoring programmes, aims to provide
assurances to the public that hospitals are meeting these Standards, and are making
any necessary quality and safety improvements that are required to fully safeguard
patients against the risk of infection.
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Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
3.
The monitoring programme
3.1
The programme aims and objectives
The aim of the Infection, Prevention and Control Standards together with the
monitoring programme is to contribute to the reduction and prevention of Healthcare
Associated Infection. This monitoring programme is aligned to the Authority’s mission
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 and will operate with the
Authority’s values:
Our mission
The mission of the Authority is derived from the statutory functions described in the
Health Act 2007 and can be summarised as:
“Drive high quality and safe care for people using our health
and social services.”
Our values
 Putting people first — we will put the needs and the voices of patients, and
those providing them, at the centre of all of our work.
 Fair and objective — we will be fair and objective in our dealings with people
and organisations, and undertake our work without fear or favour.
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Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
 Open and accountable — we will share information about the nature and
outcomes of our work, and accept full responsibility for our actions.
 Excellence and innovation — we will strive for excellence in our work, and
seek continuous improvement through self-evaluation and innovation.
 Working together — we will engage with people providing and people using the
services in developing all aspects of our work.
Find out more on the Authority’s website: www.hiqa.ie.
The Authority has designed an evidence-based monitoring approach and developed a
monitoring guide and associated tools. The monitoring programme should influence
hospital’s adoption and implementation of evidence-based practice that is known to
contribute to the prevention and control of Healthcare Associated Infections. In order
to contribute to reducing Healthcare Associated Infections and drive quality and
safety, the Authority will:

Assess if hospitals have the essential elements in place to prevent and control
Healthcare Associated Infections, with a particular focus on environmental
hygiene, hand hygiene and the effective implementation of evidence based
infection prevention care bundles.

Establish if failure to have these essential elements in place poses a serious risk
to the health or welfare of patients.

Seek assurances from hospitals that they are safeguarding patients through
the mitigation of high risks.

Carry out unannounced on-site inspections of the environment, equipment and
hand hygiene in order to assess the hygiene as experienced by patients at that
given time.

Monitor the implementation of care bundles in order to assess that the
general principles of best practice are applied in the management and care of
patients in whom an invasive medical device, such as a peripheral vascular
catheter (PVC) or a urinary catheter are being used.

Provide hospitals with the findings of the inspections so that hospitals develop
and publish prioritised quality improvement plans (QIPs).

Inform the public through the publication of the Authority’s findings.
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Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
3.2
The monitoring approach for unannounced inspections
The Authority commenced it’s monitoring programme against the National Standards
for the Prevention and Control of Healthcare Associated Infection in the last quarter
of 2012 and continued throughout 2013 and 2014. In 2015, unannounced
inspections will continue to be undertaken in acute public hospitals. If the findings
from an inspection are deemed to be sufficiently unacceptable, the Authorised
Persons will carry out a second inspection within six weeks of the first inspection.
The format followed for the second inspection will be tailored towards inspection of
the issues identified during the first inspection. This approach intends to drive rapid
improvement between assessments. The reasons for the intended re-inspection, and
general nature of that inspection will be communicated to the hospital following the
first assessment.
The monitoring programme will predominantly focus on the essential capacity and
capability factors necessary to implement three of the practices that international
research has shown to contribute significantly to reducing Healthcare Associated
Infections and improve patient safety:1
1. Hand hygiene compliance, and the systems in place in hospitals to support
good practice with hand hygiene.
2. The cleanliness of the environment and equipment.
3. The effectiveness in implementation and monitoring in use of infection
prevention care bundles, for example peripheral vascular catheter care
bundles and urinary catheter care bundles.
3.3





Authorised Persons
Inspections will be conducted by Authorised Persons, employed by the
Authority.
Authorised Persons are appointed in accordance with section 70 of the Health
Act 2007 for the purposes of monitoring compliance with standards.
All Authorised Persons will carry an authorisation card together with a form of
personal identification.
Authorised Persons will work within the powers described in the Health Act
2007.15
All Authorised Persons must comply with the Authority’s Code of Conduct,16
which is available on the Authority’s website, www.hiqa.ie.
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Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
3.4
Unannounced inspections
The aim of unannounced inspections is to assess hygiene in the hospital as observed
by the inspection team and experienced by patients at any given time. It focuses
specifically on the observation of the day-to-day delivery of services and in particular
environment and equipment cleanliness, and compliance with hand hygiene practice.
In addition, following the publication of this guidance document, the Authority will
also commence monitoring of practice in the implementation of infection prevention
care bundles, as recommended in numerous national best practice guidance
publications. In particular this monitoring will focus upon peripheral vascular catheter
and urinary catheter care bundles, but assessment of performance may include other
care bundles as recommended in prior national guidelines as the situation arises.
 Inspections will generally be within core working hours. However, weekend and





out-of-hours inspections may be carried out.
Authorised Persons, on arrival at the hospital site, will contact the hospital Chief
Executive Officer (CEO)/hospital General Manager/Person in Charge.
The Authorised Persons will use the Hygiene Observation Tool (See Appendix 1)
to gather information about the environment and hand hygiene compliance.
Documents and data will be reviewed on site during the inspection.
Staff practices for the prevention and control of Healthcare Associated Infections
may be observed.
Authorised Persons will also talk to staff members about their role and practice in
the context of the Standards. These members of staff will be identified as the
observation is taking place, and will vary in role (for example, medical staff,
nursing staff, and support staff).
3.4.1 The inspection
The aim of the inspection is to gather information about the cleanliness of the
hospital’s environment and its facilities, as well as the hospital’s performance in
relation to hand hygiene and effective implementation of infection prevention care
bundles. The main focus of the inspection relates to Standards 3, 6 and 8 of the
National Standards for the Prevention and Control of Healthcare Associated
Infection1, but other Standards may be observed and reported on if concerns arise
during the course of an inspection. It is important to note that the Standards may
not be assessed in their entirety during an inspection and therefore findings reported
are related to selected criteria within a particular Standard.
In line with the Authority’s inspection programme for 2014, re-inspections will be
carried out in some hospitals within six weeks of the first inspection where
performance is deemed to be poor during initial inspection. The format followed for
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Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
re-inspections will continue to be tailored towards inspection of the issues identified
during the first inspection and an assessment of any improvements observed
between the first and second inspections. The aim of re-inspections is to rapidly
drive improvement in relation to poor practice or performance identified during the
initial inspection. The inspection will also take into account any previous Quality
Improvement Plans (QIPs) that the hospital may have produced in response to prior
inspections from the Authority. Inspection will aim to determine progress in the
implementation of these QIPs as part of the overall monitoring approach at each
hospital.
3.4.2 Before the inspection
Prior to an inspection, key pieces of information relating to the hospital such as
previous inspection reports, any relevant information received by the Authority
relating to the hospital, and data that the hospital has published, such as QIPs and
hospital performance in the national hand hygiene audits are examined by the
inspection team. Particular issues that may need to be addressed during the
inspection are discussed by the inspection team in preparation for the inspection.
3.4.3 During the Inspection
On the day of the unannounced inspection, the inspection team contacts the hospital
Chief Executive Officer (CEO)/hospital General Manager (GM)/Person in Charge on
arrival at the hospital and informs them of the general plan for the inspection.
Hygiene observation tools are used by the inspection team to gather information
about the cleanliness of the environment and equipment as well as monitoring hand
hygiene practice in one to three clinical areas depending on the size of the hospital.
The inspection team may talk with staff and patients during the inspection and
review documentation at both ward and senior management levels. At least three
sources of information are gathered and analysed by the inspection team to assess
the level of compliance with the Infection, Prevention and Control Standards.1 This
process is known as ‘triangulation’ and is shown in Figure 1 below.
Details on key findings from the inspection are communicated by the inspection
team to Ward Managers and Senior Management during the inspection. In addition,
specific issues identified by the inspection team which are considered to present a
risk to the health or welfare of patients are assessed using the Authority’s Risk
Matrix (Appendix 2) to determine the likelihood and the impact of the identified
risks. The inspection team will inform the Senior Management team during the
inspection of any high risks which require immediate action to allow them to put the
necessary actions in place to address the risks. High risks are also escalated in line
with the Authority’s escalation process (Appendix 3) which includes formal written
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Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
notification of the identified risk to the CEO/GM and the requirement to formally
report back to the Authority with an action plan to reduce and effectively manage
the risk. The risk is also communicated to relevant Hospital Group and Health
Service Executive senior management.
Documentation
Compliance
Observation
Talk with staff
and patients
Figure 1: Triangulation of Evidence.
3.4.4
Observation, and discussion with staff and patients
In order to obtain information about the environment and physical facilities for the
prevention and control of Healthcare Associated Infections, Authorised Persons will
observe the environment. The areas to be inspected will be selected by Authorised
Persons on the day of the inspection.
The observation component will typically include inspection of between one and
three clinical areas dependent upon the relative size of the hospital. Once the areas
have been selected for observation, the Authorised Persons will meet with the
member of staff responsible for that area, and discuss practices and performance
related to Infection Prevention and Control. Authorised Persons may also revisit
areas previously inspected to determine progress in implementation of prior hospital
quality improvement plans.
The Authorised Persons will also assess hand hygiene using a broad approach. This
will include an assessment of the hospital’s progress in implementing the five key
areas of the multi-modal strategy recommended by the WHO to improve hand
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Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
hygiene compliance.8 The adoption of this approach is strongly evidence based,17-22
and is recognised and supported both nationally and internationally as a strategy to
promote reliably high achievement of optimal practice in hand hygiene. The key
areas of the multi-modal strategy are;
 system change (creating a physical environment that makes performing




hand hygiene easier and therefore more likely to happen)
training and education
evaluation, audit and feedback
reminders in the workplace
the implementation of measures to promote an effective institutional
culture of safety.
Authorised Persons will observe hand hygiene opportunities using a small sample of
staff in the clinical areas of the hospital where inspection is underway. This is
intended to replicate the experience at the individual patient level over a short
period of time. It is important to note that the results of the small sample observed
are not statistically valid and therefore should not be used to draw conclusions on
hand hygiene compliance in all groups of staff, and across the hospital as a whole.
The data derived are not intended for, and should not be used for the purpose of
external benchmarking.
The underlying principles of hand hygiene opportunities are based on the
observation of the ‘Five Moments for Hand Hygiene’ that are promoted by the WHO.8
These are:
 before touching a patient
 before clean/aseptic procedure (for example, the hand hygiene practice of
staff accessing medical invasive devices such as vascular catheters and
urinary catheters)
 after body fluid exposure risk
 after touching a patient
 after touching a patient’s surroundings.
In addition to hand hygiene opportunities, other important components of hand
hygiene will be observed by the Authorised Persons, as advised in national hand
hygiene guidelines.23,24 Such observance will include:
 the technique used for hand hygiene – where an unobstructed,
uninterrupted view of the episode occurs
 the duration of hand hygiene action
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Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
 the presence of physical barriers such as wrist and hand jewellery (except
plain wedding bands), false nails, nail varnish or long sleeves covering the
wrist area.
Following the publication of this guidance document, the Authority will also
commence monitoring of hospital performance in the implementation, ongoing
utilisation and audit of the use of infection prevention care bundles. This will require
Authorised Persons to discuss details in relation to the implementation of infection
prevention care bundles with frontline staff on wards, and observe their
implementation in practice with the assistance of staff. The Authority will
predominantly focus on assessment of peripheral vascular catheter, and urinary
catheter care bundles. However other infection prevention care bundles which have
been advised for implementation in national guidelines, for example for central
vascular catheters and ventilator associated pneumonia, may also be assessed in the
clinical setting should it be relevant to the patient population on the ward in
question.
3.4.5. Documentation review
Authorised Persons will review documentation relating to the cleanliness of the
physical environment, such as environmental hygiene audits. Documentation relating
to the management of equipment, linen, water systems and waste disposal will also
be reviewed (See Appendix 1). In particular, copies of the following documents will
be explicitly requested from senior management at the beginning of the inspection:
 the hospital’s infection prevention and control annual report for 2014
 the hospital’s infection prevention and control programme plan for 2015
 policies related to hand hygiene, including training, audit and uniform
policies.
Other components of the management of care bundles and the impact on patients
will be assessed. These include:
 policies procedures and guidelines related to all infection prevention care
bundles that are in use in the hospital
 monitoring of adherance to care bundle implementation at a ward/unit and
hospital wide level
 an assessment of the systems in place for surveillance of catheter
associated urinary tract infections (CAUTI), and the rate of CAUTI
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Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
 an assessment of the systems in place for surveillance of intravascular
catheter-related infections and catheter related blood stream infections
(CRBSI), and the rate of CRBSI
 an assessment of the measures in place to feedback performance to staff
at ward and hospital level of care bundle implementation adherence rate,
and associated invasive device infection rates (eg CAUTI, CRBSI)
 other preventative strategies in place to prevent infections associated with
invasive medical devices to include communication, risk identification,
education, training records, feedback, audit, root cause analysis, reporting,
and other quality improvement measures
 methods to ensure patient information on intravascular catheters, urinary
catheters and infection prevention.
Should these be unavailable on the day of inspection, the Authority may request that
these be provided by the hospital post-inspection to inform the overall evaluation.
With respect to hand hygiene, training records and the results of hand hygiene
audits will be reviewed and included as part of the findings of the report. The results
of national hand hygiene audits which are reported by acute hospitals to the HSE
Health Protection Surveillance Centre, and published on their website www.hpsc.ie,
will also be examined and reported upon.
The review of local audits will also focus on quality improvement programmes
associated with these audits. Records and audits may also be viewed at a corporate
level within the hospital.
18
Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
4.
After inspection
4.1.
Risk identification, assessment and notification
During the course of inspections, Authorised Persons may identify specific issues that
they believe may present a risk to the health or welfare of patients (please note this
applies to any risk identified and may not be related to the National Standards for
the Prevention and Control of Healthcare Associated Infection).





If risks are identified, the Authorised Persons will use the Authority’s Risk
Matrix (Appendix 2) to assess the likelihood and the impact of the identified
risks.
Any high risks to the health or welfare of patients identified during the
inspection will be escalated in line with the Authority’s escalation process
(Appendix 3).
High risks which require immediate mitigation, will be brought to the
attention of the accountable person(s) for the service at the time of the
inspection.* This is to allow them to implement the actions necessary to
mitigate such risks. Formal written notification of the identified risk will also be
issued to the accountable person(s) within two working days of the risk
identification, with the requirement to formally report back to the Authority
stating how the risk has been mitigated within two working days of the risk
identification.
In the case of high risks which do not require immediate mitigation, formal
written notification of the identified risk will be issued to the person(s)
accountable for the service within two working days of the risk identification
with the requirement to formally report back to the Authority with an action
plan to reduce and effectively manage the risk within five working days of
the risk identification.
Details of any risks identified which relate to the National Standards for the
Prevention and Control of Healthcare Associated Infection will be included in
the report of the monitoring inspection.
Identified individual who has overall executive accountability, responsibility and authority for the
delivery of high quality, safe and reliable services.
*
19
Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
4.2 Findings


Authorised Persons will judge the level of a hospital’s performance against each
standard criterion assessed.
The Authority will provide hospitals with a report of findings of the inspection to
outline performance on the day of the inspection, and identify scope for
improvement if necessary.
20
Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
5.
The Report
The purpose of inspection reports is to provide assurance to the public that hospitals
have implemented and are meeting the aspects of the National Standards for the
Prevention and Control of Healthcare Associated Infection inspected against. In
addition, where room for improvement is identified, these inspections intend to drive
improvement in hospital infection prevention and control practice.







The inspection report will outline the Authority’s overall assessment in relation
to the inspection, and includes key findings of relevance. A list of additional
low-level findings relating to non-compliance with the standards will be
provided to the hospital for completion. However the Authority’s overall
assessment, which will be cogniscent of these low-level findings allied to the
higher level findings, will be fully outlined in the published report.
In some circumstances, re-inspection may also need to occur to promote rapid
improvement. Where this occurs, a single report will be generated following the
second inspection. This report will include the key findings of both inspections
and any improvements observed between the first and second inspections.
The report will direct hospitals to develop and publish prioritised quality
improvement plans (QIPs) in order to provide assurance to patients and the
public. In addition, each report will take note of progress achieved in
implementing prior QIPs related to the Standards as a result of previous
inspections.
Details of any risks identified which come under the remit of the National
Standards for the Prevention and Control of Healthcare Associated Infection will
be included in the report of the inspection.
In the case of a single inspection, the Authority will send a copy of the draft
report together with a feedback form to the identified accountable person(s)
within 10 working days of the on-site inspection. This is to allow the
accountable person the opportunity to review the draft report and provide
feedback in line with due process.
Where a reinspection is deemed to be necessary within six weeks of the initial
inspection, a final report will be compiled with findings from both the first
inspection and the reinspection contained within. In this situation, the Authority
will provide a copy of this draft report with a feedback form to the identified
accountable person(s) within 20 working days of re-inspection.
The accountable person(s) should complete the feedback form provided with
the report, and return this to the Authority within five working days of
receipt of the draft report and feedback form.
21
Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority

5.1


The Authorised Persons will review the feedback and may make changes, as a
result of the feedback provided by the accountable person, prior to finalising
the report for publication.
Publication of reports
The findings of inspections are made publicly available and are published on
the Authority’s website, www.hiqa.ie.
The Authority will provide a copy of the final report to the identified
accountable person(s) prior to publication. In addition, information in relation
to the monitoring programme will be communicated to relevant senior
personnel within the Health Service Executive. This is set out in Appendix 4.
22
Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
6.




Expected hospital response
In the event that the Authority identifies high risks (either immediate or nonimmediate), it is the responsibility of the hospital to respond as previously
outlined in section 4.
Each hospital is accountable for the development of a quality improvement plan
(QIP) that identifies the improvements necessary to comply with the Infection,
Prevention and Control Standards. In designing their QIP, each service provider
must ensure that each risk identified by the inspection process is directly
addressed.
Each QIP must be approved by the hospital’s accountable person - who has
overall executive accountability, responsibility and authority for the delivery of
high quality, safe and reliable services. The QIP should outline each risk
identified, the proposed action(s) intended to address that risk, a timeline to
complete each action, and an identified person who will be responsible for
ensuring each task is completed.
Each hospital must publish and make its QIP accessible on its website within
six weeks of the date of publication of the Authority’s report. At that time, the
hospital must also provide the Authority with details of the web link to its QIP.
As the QIP is implemented over time, the hospital should update its website to
publically demonstrate progress against the proposed plan and indicate to the
Authority that this has taken place.
23
Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
7.

Continuous monitoring post inspection
It is the responsibility of the hospital to design their QIP, provide the necessary
resources to enable it to progress within the required timeframe, and fully
implement its QIP to completion. The Authority will continue to monitor the
status of the hospital’s QIP, alongside other relevant outcome measurements
and key performance indicators. This overall continuous monitoring approach
may include:
 review of data and other relevant documents (including publicly-available







information)
review of the hospital’s QIP
information provided by other regulators
information provided by patients
meetings with hospitals
meetings with patients
hospital feedback.
Once the various sources of information have been analysed and the risks have
been assessed, the Authority’s responses may include:
 seeking the necessary assurance from the hospital that it is safeguarding





patients through the mitigation of risk
hospital interview to clarify any issues, and identify how it is managing
potential risk
a second inspection within six weeks of the first inspection
advising the hospital group CEO of the Authority’s concerns
advising the HSE and/or the Minister for Health of the Authority’s concerns
undertaking an investigation as to the safety, quality and standard of the
services if the Authority believes there is a high risk to the health and
welfare of a person receiving services and that the risk may be the result of
any act, failure to act or negligence on the part of the HSE or a
hospital/hospital group.
24
Page 25 of 64
Appendix 1 – Hygiene Observation Tool
National Standards for the Prevention and Control of Healthcare Associated Infections
Observation Tool for Unannounced Monitoring Inspections
Hospital:
____________________________________________________________________
Date/Time (start and finish) of Assessment:
____________________________________________________________________
Area(s) Assessed:
____________________________________________________________________
Authorised Persons (insert initials):
Lead:
_______________________________________________________________
Initial Discussion with CEO/ General Manager
Name/Title:
____________________________________________________________________
Name/Title of other attendees present
____________________________________________________________________
Page 26 of 64
Number of beds open:
_____________________________________________________________________________
Are there any infection risks in the hospital
that we need to be informed about?:
____________________________________________________________________
Has there been an outbreak in the last month:
____________________________________________________________________
Are there any building works ongoing?:
____________________________________________________________________
__________________________________________________________________________________________________
Is the Infection Prevention and Control Team
involved in providing advice relating to mitigating
potential risk to patients posed by building works?:
___________________________________________________________________
What education/communication has been conducted with staff to minimising the risk of Aspergillus infection during these
works?:
____________________________________________________________________________________
___________________________________________________________________________________________
Page 27 of 64
Hospital Layout
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Proceed to areas selected for observation
Area/Speciality/Time:
____________________________________________________________________
Initial discussion with Area Manager/person responsible for that area
Name/Title:
_______________________________________________________________
Ward Layout/No. of Beds/No. of isolation rooms:
_______________________________________________________________
Page 28 of 64
Single
 x __
4-bedded
 x __
8-bedded
 x __
2-bedded
 x __
5-bedded
 x __
En-Suite
 x __
3-bedded
 x __
6-bedded
 x __
Other
 x __
How many patients are currently accommodated on the ward? _________________________________
How many patients are isolated?: _______________________________________
How are isolation rooms allocated?:
Single En-Suite
 x __
Single
 x __
Cohorted
 x __
If cohorted, how are rooms allocated?:
_______________________________________________________________
______________________________________________________________________________________________
Are there any restricted areas?:
____________________________________________________________________
______________________________________________________________________________________
Page 29 of 64
Section A: General Environment
Yes
No
Yes
1.
The facility is clean and well maintained
7.
Skirting boards
2.
The corridors are clutter free
8.
Signage
3.
Air vents – are these on a cleaning programme
9.
Walls
4.
Curtains and blinds
10.
Windows
5.
Floors incl. edges and corners
6.
Radiators
No
Issues Identified:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Page 30 of 64
Section B: Patient Areas
1.
Bed frames
Yes
No
Yes
6.
Fixtures are clean incl. switches,
sockets, data points, light fittings,
call bells
2.
Bedside storage
7.
Floors incl. edges and corners
3.
Bedside tables
8.
High and low surfaces
4.
Chairs/stools covered in impermeable intact
material
9.
5.
Curtain rails
No
Mattresses/Covers/Pillows
Issues Identified:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Page 31 of 64
Section C: Patient Equipment
Yes
No
Yes
1.
Blood pressure cuffs
11.
Oxygen equipment plus nebulisers
2.
Cardiac monitors
12.
Resuscitation trolley
3.
Commodes
13.
Stand aids and accessories
4.
Dressing trolleys
14.
Suction apparatus
5.
Hoists and accessories
15.
Temperature probes
6.
IV pumps/syringe drivers
16.
Wheelchairs and cushions
17.
Work station and equipment in clinical areas is
visibly clean incl.
phones/computers/keyboards/fax machines
7.
IV stands
9.
Near patient testing equipment, e.g.
blood gas machines, blood glucose
monitors
Observation
monitoring trolley
10.
Oxygen saturation probes
8.
18.
19.
No
Is there a responsible person for cleaning work
station and equipment?
Patient notes trolleys
Issues Identified:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Page 32 of 64
Section D: Patient Toilets/Washrooms
1.
2.
3.
4.
5.
Toilets/washrooms are clean, tidy, well maintained,
free of rust, blood or body substances, dust, debris,
spillages and clutter. This is monitored and records are
maintained
Baths and accessories
Foot operated non-clinical waste disposal bin is
available
High
and low surfaces and wall tiles
Hand washing facilities incl. liquid soap and paper
towels
Yes
No
Yes
6.
7.
8.
9.
10.
No
Sanitary waste disposal
available
Showers and accessories
Sinks/components/accessories
Toilets/seats/accessories
Air vents
Issues Identified:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Page 33 of 64
Section E: Clean Utility
Yes
No
Yes
1.
A foot operated non-clinical waste disposal
bin is available
7.
Clinical hand wash sinks including
component parts, should be clean and well
maintained with no blood, body substances,
rust, dust, debris or spillages
2.
A foot operated clinical waste disposal bin
is available
All equipment both in use and storage,
including component parts, should be clean
and well maintained with no blood, body
substances, rust, dust, dirt, debris or
spillages
8.
Equipment/supplies are stored
appropriately
Liquid soap, warm water and paper hand
towels and alcohol hand rub are available
4.
All sterile stock is in date
10. The environment is tidy, well maintained,
free of rust, blood, body substances, dust,
dirt, debris, spillages and clutter
5.
Appropriate designated clinical hand wash
sinks are available. They should be
appropriately located, accessible and free
from
obstruction
Clinical
areas signage should be clean,
11. The room is secure (check if risk
assessment done if not secure)
3.
6.
9.
No
updated, well maintained and laminated if
paper based signage is used
Issues Identified:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Page 34 of 64
Section F:
Dirty Utility
Yes
No
Yes
1.
A foot operated clinical waste disposal bin is
available
9.
2.
A foot operated non-clinical waste disposal
bin is available
3.
A macerator/bed pan washer is available,
fully functioning and within service date
Appropriate designated hand washing
facilities incl. availability of liquid soap and
paper towels
A separate sink is available for cleaning
patient equipment and is clean
A sluice hopper is available for the disposal of
body fluids and is clean
10. Signage should be clean, updated,
securely fixed, well maintained and
laminated if paper based
11. The integrity of fixtures and fittings is
intact
12. There is no inappropriate storage of items
4.
5.
6.
7.
Floors including edges and corners are free of
dust and grit
8.
High and low surfaces and wall tiles
No
Patient washbowls/bed pans should be
decontaminated between each patient and
stored clean, dry and inverted
13. The room is secure (check if risk
assessment done if not secure)
14. Used instruments are safely stored in an
appropriate container prior to collection
for autoclaving
Issues Identified:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Page 35 of 64
Section G: Waste Disposal
1.
2.
A foot operated clinical waste disposal
bin is available
A foot operated non-clinical waste
disposal bin is available
Yes
No
Yes
6.
3.
4.
5.
tagged and secured before
leaving the area of production

stored in a secured designated
sub-collection area at point of
origin (e.g. ward, clinic) until
collection
Primary healthcare risk waste packages
must not be stored in corridors or other
locations accessible to unauthorised
personnel
Rigid bins are no more than 3/4 full or
filled above manufacturer’s guidelines*
Waste bags are no more than 2/3 full
Waste receptacles are:
7.
Clinical waste should be:

No
8.
9.


labelled correctly
clean, well maintained and the lids
are closing correctly
Waste should be segregated, and segregation
should adhere to national colour coding
Within healthcare risk waste, all special waste
including drugs and cytotoxic drugs or
materials are appropriately segregated
10. Evidence of education on waste management
for staff (ask staff member)
Issues Identified:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Page 36 of 64
Section H: Sharps Management
1.
2.
3.
4.
An empty sharps bin is available on the
resuscitation trolley
Sharps bins have not been over filled
above the manufacturer’s guideline and
are free of protruding sharps
Sharps bins have been assembled
correctly and details completed
Sharps trays with integral sharps bins are
available for use at the point of care
Yes
No
Yes
5.
6.
No
The temporary closing mechanisms on
sharps bins are engaged
The brackets and frames for sharps bins
are clean
Issues Identified:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Page 37 of 64
Section I:
Isolation Rooms
Yes
No
Yes
1.
Are patients who need contact isolation
precautions isolated in a single room or cohorted
appropriately?
8.
Is hand hygiene performed after
removal of PPE and prior to leaving the
room?
2.
A risk assessment is documented in patient
notes/care plan if isolation is not possible
9.
Isolation rooms have a designated hand
hygiene sink
3.
Are patients isolated with contact precautions
provided with designated en-suite toilet
facilities/commode and dedicated patient
equipment?
10. Is there a negative/neutral pressure
isolation room for patients requiring
airborne precautions?
4.
Are pressure settings visibly displayed and
monitored?
5.
Appropriate signage incl. precautionary signage
should be clean, up to date, well maintained and
laminated if paper based signage is used
11. Is there a policy for the negative
pressure room which is accessible for
staff on the ward?
12. Personal Protective Equipment (PPE) is
available and used appropriately incl.
donning, doffing and disposal
6.
Doors to isolation rooms should be in the closed
position
7.
Foot operated waste disposal bins are available
and are appropriately placed
No
13. Education on transmission based
precautions and standard precautions
are provided for staff every two years
Issues Identified:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Page 38 of 64
Section J:
Cleaning/Housekeeping Equipment and
Room
Yes
No
Yes
1.
All cleaning equipment is clean and appropriate
6.
2.
All storage facilities for cleaning equipment are clean and
appropriate
Appropriate advisory signage is in place for the use of
products used for cleaning and disinfection
A warning sign, “cleaning in progress”, must always be
used and positioned to be effective
Bottles for storage of diluted products should be cleaned
after use
7.
3.
4.
5.
8.
Cleaning products should be
stored appropriately in locked
cupboards hand hygiene
Designated
facilities should be available
PPE should be available
9.
The room should be secure
10.
A colour coded cleaning
system is in use in line with
national guidelines?
No
Issues Identified:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Page 39 of 64
Section K: Discussion with staff who have
responsibility for cleaning
1.
What PPE do you use and when?
2.
What products do you use to clean and disinfect the
area?
3.
How do you know the correct dilution?
4.
How do you discard the solution?
5.
Are you using a colour coded cleaning system? What
is it?
6.
How do you maintain the cleaning equipment?
7.
Have you ever attended hand hygiene training?
When?
8.
Do you have safety data sheets for cleaning
products?
9.
Are you using a colour coded waste system? What is
it?
10.
How would you dispose of a contaminated item?
Yes
No
Comments
Page 40 of 64
Section L:
Hand Hygiene Practices
Yes
No
Yes
1.
Alcohol based hand rub should be available at
main entrances and at the point of care in
clinical areas
7.
Liquid soap, warm water and paper hand
towels are available
2.
Clinical hand wash sinks should conform to
HBN 00-10
Designated clinical hand wash sinks are in all
areas where clinical activities are performed.
They should be appropriately located,
accessible and free from obstruction
Hands free operated waste disposal bins are
available near sinks to dispose of used paper
towels
Hand hygiene advisory posters and
8.
Taps should be hands free and
thermostatically regulated
The nozzles of wall mounted alcohol gels
and hand disinfectants are clean
3.
4.
5.
information leaflets are available, up to date,
clean and appropriately displayed throughout
the organisation including “Have you washed
your hands?” posters
6.
9.
10.
Patient participation and education on
hand hygiene
11.
Evidence of bare below elbow in clinical
areas
No
Hand wash facilities are clean and intact
(check sink, tap, sealant and back splash)
Issues Identified:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Page 41 of 64
Section M: Linen
Yes
No
Yes
1.
Are alginate bags used for soiled linen?
6.
2.
Are curtain changes on a planned
programme and clean?
7.
3.
Bags are less than 2/3 full and capable of
being secured
8.
Linen storage area is clean and free
from dust and inappropriate items
4.
Check linen policy guidelines
9.
Stored curtains are clean and free
from stains
5.
Clean linen is free from stains
No
Clean linen is stored in an
appropriate designated area
separate from used linen
Linen is segregated into appropriate
colour coded bags
Issues Identified:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Page 42 of 64
Section N: Peripheral Vascular Catheter
Care Bundles
Yes
No
Yes
1.
There is a policy/procedure/guideline/care
bundle in place for both the insertion and
maintenance of Peripheral Vascular Catheters
on this ward?
7.
Is the dressing used to cover the PVC
intact and clean? (obtain verbal consent
from patient, and check IV dressing with
the assistance of the nurse)
2.
List each of the elements of the peripheral
vascular catheter care bundle outlined in this
policy
8.
3.
Is there evidence on the ward that all PVCs are
inspected at least daily for signs of
inflammation/infection? (documentation/ask
staff)
9.
From observation on the ward, are hand
hygiene and other standard precautions
adhered to prior to accessing,
manipulating or handling peripheral
cannulae?
Are intravenous infusions maintained as
4.
Is there evidence that medical invasive devices
are removed when either infected, blocked or
no longer required. (check documentation/ask
staff member)
10.
Is compliance with all elements of the
care bundle measured and fed back to
staff?
5.
Select one patient on the ward who has a PVC.
Is there a documented clinical indication for
insertion of the PVC? ( documentation/ask staff
member)
11.
Are peripheral vascular catheter site and
peripheral vascular catheter related
bloodstream infection rates recorded and
reported to senior management?
6.
Are all elements of the hospitals PVC care
bundle in place for this patient?
12.
Are peripheral vascular catheter site and
peripheral vascular catheter related
bloodstream infection rates reported to
ward level staff?
closed systems?
No
Page 43 of 64
Issues Identified:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Page 44 of 64
Section O: Urinary Catheter Care Bundles
1.
Yes
No
Yes
Is there a policy/procedure/guideline/care
bundle in place for both the insertion and
maintenance of Short-term Urinary Catheters
on this ward?
9.
Are urinary catheter drainage systems
maintained as closed systems?
List each of the elements of the short-term
urinary catheter care bundle outlined in this
policy
10.
Is there evidence that daily meatal
hygiene is carried out?
(Documentation/ask staff)
5.
Is there evidence on the ward that all urinary
catheters are inspected at least daily for signs
of inflammation/infection?
(documentation/ask staff)
11.
Are urinary catheter drainage systems
maintained as closed systems?
6.
Is there evidence that urinary catheters are
removed when either infected, blocked or no
longer required. (check documentation/ask
staff member)
12.
Is an appropriate clean container is used
for emptying urinary catheter bags?
7.
Select one patient on the ward who has a
short-term urinary catheter. Is there a
documented clinical indication for insertion of
the catheter? (documentation/ask staff
member)
Are all elements of the hospitals urinary
catheter care bundle in place for this patient?
13.
Is compliance with all elements of the
care bundle measured and fed back to
staff?
14.
Are urinary catheter site and urinary
catheter related bloodstream infection
rates recorded and reported to senior
management?
8.
No
Page 45 of 64
15. From observation on the ward, are hand
hygiene and other standard precautions
adhered to prior to accessing, manipulating or
handling urinary catheters?
16.
Are urinary catheter site and urinary
catheter related bloodstream infection
rates reported to ward level staff?
Issues Identified:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Page 46 of 64
Section P: Discussion with Area
Manager following observations
1.
What are the most recent hand hygiene
audit results for this area?
2.
How are hand hygiene audit results
disseminated to all staff in this area?
3.
How is below target compliance addressed?
4.
What processes are in place to ensure all
staff are up to date with hand hygiene
training?
5.
What processes are in place to ensure all
staff are up to date with Infection
Prevention and Control training?
6.
What are the most recent environmental
audit results for this area?
7.
How is it ensured that actions arising from
environmental audits are addressed to
completion?
Comments
Page 47 of 64
8.
9.
What process is in place for the routine
cleaning of curtains/blinds/shower curtains
incl. after a known case of an infected
patient/client? (Review documents)
What processes are in place in this clinical
area to ensure that all medical equipment is
clean and well maintained? Who is
responsible in this ward?
10.
Is there a daily cleaning schedule for
patient equipment?
11.
Who monitors the cleaning of
toilets/washrooms? (Review daily
monitoring sheets/sign off sheets)
12.
What is the process for flushing all outlets?
13.
Are patients given a survey to complete on
the environment/hand hygiene?
14.
Is there a process for monitoring
mattresses?
15.
Do you have access to the waste
management policy?
Page 48 of 64
16.
When was the last time that your bedpan
washer/macerator underwent
maintenance? Do you have access to the
maintenance records?
17..
Is there a system of auditing on the ward
which measures compliance with all
elements of the PVC and urinary catheter
care bundles, with feedback to staff?
18..
Does the hospital have a surveillance
system in place to monitor and report PVC
and urinary catheter related infection (inc
bloodsteam infection) rates to ward staff
and management?
19.
Is there an effective system in place on the
ward which ensures feedback of
performance from this surveillance system
to ward staff?
Issues Identified:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Page 49 of 64
Section Q: Discussion with Senior
Management member(s)
1.
What are the most recent hand hygiene
audit results for this hospital?
2.
How are hand hygiene audit results
disseminated to all staff in this hospital?
3.
How is below target hand hygiene
compliance addressed?
4.
What processes are in place to ensure that
all staff are up to date with hand hygiene
training?
5
What processes are in place to ensure that
all staff are up to date with Infection
Prevention and Control training?
6
Is IPC education based on a framework that
includes the core knowledge, skills and
competencies required for different groups
of healthcare staff?
Comments
Page 50 of 64
7
How often are environmental hygiene audits
carried out?
8.
What environmental controls are in place to
prevent the risk of healthcare associated
infections from water systems in this
hospital?
Who has overall responsibility for waste
management in this hospital?
9.
10.
What assurances are present to ensure that
waste generated in this hospital is managed
in accordance with national standards?
11.
Is there a system in place for monitoring and
replacing mattresses? Please describe same.
12.
Do you have a uniform policy? Does it
include a requirement for a ‘bare below the
elbow’ approach?
13.
Do you have Infection Prevention and
Control link staff? Are they involved in hand
hygiene training and auditing?
Page 51 of 64
14.
15.
16.
17.
Please describe the systems in place in your
hospital to ensure that you rapidly identify
and appropriately place patients with
suspected or confirmed multidrug resistant
organisms.
How are staff educated about screening and
isolation of patients with suspected or
confirmed multidrug resistant organisms?
What systems are in place to measure
compliance with all elements of
theperipheral vascular catheter and urinary
catheter care bundles, and feedback results
to staff?
Does your hospital monitor infection rates
related to invasive medical devices (PVCS,
UCs). If it does, what are the most recent
results?
18
How are hospital staff Educated on PVC/UC
care bundles ?
19
Does your hospital have a surgical site
infection surveillance programme?
If so please outline



Surgical procedures surveyed
Timeframe covered
How this information is used to
inform improvement efforts
Page 52 of 64
Issues Identified:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
_________________________________________________________________________________________________
Page 53 of 64
Section R: Close-Out Meeting
Name(s) and Position(s)
of Attendees:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Time: Start/Finish:
________________________________________________________________________
Meeting Notes:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Page 54 of 64
Section S: Hand Hygiene Observation Tool – At least 10 opportunities to be observed per area visited
Name of Hospital:
Name of Ward
Date:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Employee
Category
Hand Hygiene
Opportunity (HHO)
N
=Nurse/Midwif
e
D =Doctor
A =Ancillary
staff
AL =Allied
Health Staff
1 =Before touching a
patient
2 = Before clean/aseptic
procedure
3 =After body fluid
exposure risk
4= After touching a
patient
5 =After touching patient
surroundings
Hand
Hygiene
Action
Observed
after
HHO
Y = Yes
N = No
>
=
15
sec
More
than
one
plain
ring
Wearing
a Wrist
Watch
Sleeves
to
Wrist
Nail
varnish
present
False
Nails
Present
Correct
Technique
Comment
Y = Yes
N = No
U/O = Unobserved
Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
Section T: Documentation requirement: Area Level
(Area Manager Copy)
Ref
Type of Document
1
Most recent records of hand hygiene training, audit of practices and associated
improvement/action plans.
2
Most recent records of Infection Prevention and Control training for ward based staff.
3
Records of curtain changing (to include shower curtains and blinds where
appropriate).
4
Daily cleaning records for patient equipment.
5
Waste management policy.
6
Bedpan washer/macerator maintenance, service and audit records.
7
Most recent records of environmental hygiene audits and associated
improvement/action plans.
8
Records of water flushing.
Implementation plan for measures to control the spread of Gram-negative multi-drug
resistant organisms including
9




staff education,
patient screening and isolation,
patient information leaflets,
policy related to transmission based precautions
10
Most recent records of audits of peripheral vascular catheter/urinary catheter care
bundle compliance on your ward
11
Most recent recorded peripheral vascular catheter/urinary catheter related infection
rates on your ward
12
Most recent recorded rate of hospital acquired blood stream infection on your ward
55
Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
Section U: Documentation for Review
(CEO/General Manager Copy)
Ref
Type of Document
1
Records of hand hygiene training for all disciplines.
2
Most recent records of Infection Prevention and Control training for all disciplines.
3
Annual overall compliance in hand hygiene audits for the hospital, subdivided by staff
group.
4
Hygiene related audits and associated improvement/action plans.
5
Policies relating to hand hygiene to include training, audit and uniform policy.
6
Water Flushing Policy.
7
Most recent Legionella Risk Assessment document.
8
Waste Management Policy.
9
Policy for the isolation of patients suspected or confirmed as being infected or colonised
with transmissible infectious pathogens.
10
Infection Prevention and Control Annual Report 2014.
11
Infection Prevention and Control Programme Plan for 2015.
Documentation relating to your hospital implementation plan for measures to control the
spread of Gram-negative multi-drug resistant organisms including
12




staff education,
patient screening and isolation,
patient information leaflets,
policy related to transmission based precautions
13
Most recent records of audits of peripheral vascular catheter/urinary catheter care bundle
compliance across the hospital
14
Most recent recorded peripheral vascular catheter/urinary catheter related infection rates
across the hospital
15
Most recent recorded rates of hospital acquired blood stream infection in your hospital
56
Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
Appendix 2 – Risk matrix
Risk assessment process: the Authorised persons will assess the consequence of
the risk to patients and the probability of reoccurrence to determine the level of risk,
using the tables below. The consequence of the risk, and the probability of
occurrence are both assessed and given a score from 1 to 5. The risk matrix is then
used to give an overall risk score. This score then corresponds with the classification
of risk table.
Consequence of the risk: what is the actual impact of the risk?
Consequence
category
1 Negligible
Impact on individual/future patients








2 Minor
3 Moderate
4 Major


5 Catastrophic
No obvious harm
No injury requiring treatment
Minor injury
No permanent harm
Significant injury or ill health
Some temporary incapacity
Major injuries or long term incapacity or disability
Major permanent harm as result of clinical or non-clinical
incident injuries or long term incapacity or disability
Major permanent harm
Death
Probability of reoccurrence: what is the chance of this event occurring or
reoccurring? Identify the ‘probability rating’ for reoccurrence from the following
table:
Probability
Score
1
Descriptor
Frequency
Rare
This will probably never happen/reoccur
2
Unlikely
3
Possible
Do not expect it to happen/reoccur again but
it is possible
Might happen or reoccur occasionally
4
Likely
Will probably reoccur, but it is not a
persistent issue
5
Almost certain
Will undoubtedly reoccur, possibly frequently
The lead authorised person classifies the risk using the risk matrix below and
documents the findings that indicate the risk.
57
Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
Risk Matrix
Probability
CONSEQUENCE CATEGORY
Negligible
Minor
Moderate
Major
Catastrophic
(1)
(2)
(3)
(4)
(5)
Almost certain
(5)
5
10
15
20
25
Likely (4)
4
8
12
16
20
Possible (3)
3
6
9
12
15
Unlikely (2)
2
4
6
8
10
Rare (1)
1
2
3
4
5
The risk is then classified as high, moderate, low or very low as per the risk matrix
score. See classification of risk table below.
Classification of risk
Risk Matrix Score
High Risk(Red)
15, 16, 20 or 25
Moderate Risk (Orange)
8, 9, 10 or 12
Low Risk (Yellow)
4, 5 or 6
Very Low Risk (Green)
1, 2 or 3
58
Guide: Monitoring programme for unannounced inspections undertaken against the National Standards for the Prevention and Control of Healthcare
Associated Infections
Health Information and Quality Authority
Appendix 3 – Risk escalation process map
Appendix 3. HIQA National Standards for Prevention and Control of Healthcare Associated Infections - Risk Escalation Process
Risk Identified
Is risk
Moderate or
lower?
Include Risk
Detail in Report
Yes
HIQA
No
Is risk
high but not
immediate?
Yes
No
Service Provider
Is risk
high and
Immediate?
Yes
Within 6 weeks of
risk identification
Letter issued to
Accountable Person
Monitoring
Assessment
Re-Inspection
Within 2 days of
risk identification
Immediate
Inspector informs
member of HIQA
Healthcare Team
management
Within 2 days of
risk identification
Advise
Accountable
Person prior to
leaving site
Include Risk and
Response Detail
in Report
Letter issued to
Accountable Person
c.c. As per Appendix 2
Send Mitigation
Response to HIQA
Send Mitigation
Response inc Action
Plan to HIQA
Within 2 days of
risk identification
Within 5 days of
risk identification
Publish Quality
Improvement Plan
on own Website
Within 6 weeks of
Report Publication
Note:
Accountable Person: identified individual who has overall executive accountability, responsibility and authority for the delivery of high quality, safe and reliable services.
59
Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
Appendix 4 – References
1. Health Information and Quality Authority. National Standards for the
Prevention and Control of Healthcare Associated Infections. Dublin: Health
Information and Quality Authority; 2009. [Online]. Available from:
http://www.hiqa.ie/publication/national-standards-prevention-and-controlhealthcare-associated-infections.
2. World Health Organization. Report on the Burden of Endemic HealthcareAssociated Infection Worldwide. Geneva: World Health Organization Press;
2011. [Online]. Available from:
http://whqlibdoc.who.int/publications/2011/9789241501507_eng.pdf.
3. Health Protection Surveillance Centre. Point Prevalence Survey of Hospital
Acquired Infections and Antimicrobial Use in European Care Hospitals: May
2012. Republic of Ireland National Report; November 2012. [Online]. Available
4.
5.
6.
7.
8.
from:
http://www.hpsc.ie/AZ/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Surveillance/Ho
spitalPointPrevalenceSurveys/2012/PPS2012ReportsforIreland/File,14259,en.p
df.
Agency for Healthcare Research and Quality (2011). Evidence-based practice
center systematic review protocol, closing the quality gap: Prevention of
health care-associated infections.
Health Services Executive. Core Infection Prevention and Control Knowledge
and Skills:A Framework Document. May 2015. [Online]. Available from:
http://www.hpsc.ie/AZ/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Guidelines/File,
15111,en.pdf
H.P. Loveday, J.A. Wilson, R.J. Pratt, M. Golsorkhi, A. Tingle, A. Bak, J.
Browne, J. Prieto, M. Wilcox. Epic 3: National evidence-based guidelines for
preventing healthcare-associated infections in NHS hospitals in England.
Journal of Hospital Infection. 2014. S1-S70. [Online]. Available from:
http://www.sciencedirect.com/science/article/pii/S0195670113600122.
British Standards Institution 2014. PAS 5748:2014. Specification for the
Planning, Application, Measurement and Review of Cleanliness Services in
Hospitals.
World Health Organization. A Guide to implementation of the WHO multimodal
hand hygiene improvement strategy. Geneva: World Health Organization
Press; 2009. [Online]. Available from:
http://www.who.int/gpsc/5may/Guide_to_Implementation.pdf.
60
Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
9. The Royal College of Physicians of Ireland/Health Service Executive Quality
and Patient Safety Division. Prevention of Intravascular Catheter-related
Infection in Ireland. Update of 2009 National Guidelines. September 2014.
[Online]. Available from: http://www.hpsc.ie/AZ/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/IntravascularIV
lines/Publications
10. HSE Health Protection Surveillance Centre, on behalf of the Strategy for the
Control of Antimicrobial Resistance in Ireland (SARI). Guidelines for the
Prevention and Control of Catheter-associated Urinary Tract Infection. 2011.
[Online]. Available from: http://www.hpsc.ie/AZ/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/UrinaryCathete
rs/Publications
11. Royal College of Surgeons in Ireland/ Royal College of Physicians of Ireland
Working Group on Prevention of Surgical Site Infection. Preventing Surgical
Site Infections – Key Recommendations for Practice. 2012. [Online]. Available
from: http://www.hpsc.ie/AZ/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Surveillance/Su
rgicalSiteInfectionSurveillance/CareBundles
12. HSE Health Protection Surveillance Centre, on behalf of the Strategy for the
Control of Antimicrobial Resistance in Ireland (SARI). Guidelines for the
Prevention of Ventilator-associated pneumonia in adults in Ireland. February
2011. [Online]. Available from:
https://www.google.com/url?q=http://www.hpsc.ie/AZ/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Guidelines/File,
12530,en.pdf&sa=U&ei=RJvTVOCaNqqv7Ab5IDAAw&ved=0CAUQFjAA&client=internal-udscse&usg=AFQjCNGX69_6Vf1UaLji46FUkrVmefx4hQ
13. Eggimann P, Sax H, Pittet D. Catheter-related Infections. Microbes Infect.
2004;6(11):1033-42
14. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S et al. N
Engl J Med 2006;355:2725-2732
15. Health Act 2007. Dublin: The Stationary Office; 2007. Available online from:
http://www.oireachtas.ie/documents/bills28/acts/2007/a2307.pdf.
16. Health Information and Quality Authority. Code of conduct: staff conducting
statutory inspections, investigations and reviews. Dublin: Health Information
and Quality Authority. [Online]. Available from:
http://www.hiqa.ie/system/files/Code-of-Conduct-inspection-investigationsreviews.pdf.
17. Sax H, Allegrazi B, Uckay I et al. ‘My five moments of Hand Hygiene’: a usercentred design approach to understand, train, monitor and report hand
61
Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
hygiene. Journal of Hospital Infection. 2007; 67:9-21. [Online]. Available
from:
http://microbiology.mtsinai.on.ca/coreEducModules/hand-hygiene-aug2007.pdf.
18. Pittet D, Hugonnet S, Harbarth S et al. Effectiveness of a hospital-wide
programme to improve compliance with hand hygiene.Infection Control
Programme. Lancet 2000; 356:1307-12. [Online]. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/11073019.
19. Mertz D, Dafoe N, Walter SD et al. Effect of a multifaceted intervention on
adherence to hand hygiene among healthcare workers: a cluster-randomized
trial. Infect Control Hosp Epidemiol 2010;31:1170-6. [Online]. Available from:
http://www.ncbi.nlm.nih.gov/pubmed/20923288.
20. Martin-madrazo C, Soto-diaz S, Canada-dorado A et al. Cluster randomized
trial to evaluate the effect of a multimodal hand hygiene improvement
strategy in primary care. Infect Control Hosp Epidemiol 2012;33:681-8.
[Online]. Available from:
http://www.jstor.org/stable/10.1086/666343.
21. Stone SP, Fuller C, Savage J et al. Evaluation of the national Cleanyourhands
campaign to reduce Staphylococcus aureus bacteraemia and Clostridium
difficile infection in hospitals in England and Wales by improved hand hygiene:
four year prospective, ecological, interrupted time series study. BMJ
2012;344:e3005. [Online]. Available from:
http://www.bmj.com/content/344/bmj.e3005.
22. Kirkland KB, Homa KA, Lasky RS et al. Impact of a hospital-wide hand hygiene
initiative on healthcare-associated infections: results of an interrupted time
series. BMJ Qual Saf 2012;21(12):1019-26
23. Strategy for the Control of Antimicrobial Resistance in Ireland (SARI).
Guidelines for Hand Hygiene in Irish Health Care Settings. Update of 2005
guidelines. January 2015 [Online]. Available from: http://www.hpsc.ie/AZ/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Guidelines/
24. Strategy for the Control of Antimicrobial Resistance in Ireland (SARI). Hand
Hygiene Observation Audit: Standard Operating Procedure 2014. [Online].
Available from:
https://hpsc.ie/AZ/Gastroenteric/Handwashing/HandHygieneAudit/HandHygieneAuditTools/File,
12660,en.pdf.
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Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
63
Guide: Monitoring programme for unannounced inspections undertaken against the National
Standards for the Prevention and Control of Healthcare Associated Infections
Health Information and Quality Authority
Published by the Health Information and Quality Authority.
For further information please contact:
Health Information and Quality Authority
Dublin Regional Office
George’s Court
George’s Lane
Smithfield
Dublin 7
Phone: +353 (0) 1 814 7400
Email: qualityandsafety@hiqa.ie
URL: www.hiqa.ie
© Health Information and Quality Authority 2015
64