Standards › Standard BASIS › Policies
Policy · IPC-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: B1.15
At a glance
- The facility has a written infection prevention and control (IPC) programme with a named lead, reviewed at least once a year.
- Hand hygiene, personal protective equipment, isolation and cleaning are in place at every point of care.
- Healthcare-associated infections are counted every quarter, and each cluster is investigated and acted on.
- The programme is approved by the governing body and reported to it each year.
- Stop and get help straight away if: there is no written programme or named lead, or a cluster of infections has no recorded investigation.
1. Purpose
To prevent healthcare-associated infection to patients, staff and visitors through a written, reviewed and monitored programme (B1.15).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Healthcare-associated infection | An infection a patient acquires during care in the facility, not present or incubating on admission. |
| Cluster | Two or more linked cases of the same infection in the same area within a short period, or an unusual pattern of one infection. |
| Standard precautions | Basic measures used for every patient: hand hygiene, PPE, safe handling of sharps and waste, and respiratory hygiene. |
| Isolation | Additional precautions for a patient with, or suspected of having, an infection that can spread. |
4. Background
To prevent healthcare-associated infection to patients, staff and visitors through a written, reviewed and monitored programme (B1.15).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| IPC lead | Runs the programme, leads surveillance and outbreak response, and reports to the clinical director each quarter | Clinical director |
| Clinical director | Approves the programme, provides resources, and reports to the governing body each year | Governing body |
| Ward and department leads | Make sure hand hygiene, PPE, isolation and cleaning are done in their area, and report problems | IPC lead |
| All staff | Apply standard precautions at every patient contact and report exposures and infections | Ward lead |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Prevent.
- Apply standard precautions at every patient contact, and use the 5 Moments of hand hygiene (HH-SOP-001).
- Put a patient in isolation when an infection is suspected or confirmed, following the isolation check (DIA-FRM-007 and the isolation procedure).
Key point: Precautions applied.
Step 2. Detect.
- Count healthcare-associated infections each month and summarise them each quarter in the surveillance register (IPC-REG-001).
- Audit hand hygiene compliance each month (HH-FRM-001).
Key point: Infections counted and audited.
Step 3. Respond.
- When a cluster is seen, the IPC lead investigates within 24 hours, decides on measures, and records the action and the outcome.
- Inform the clinical director the same day if the cluster is serious or unusual.
Key point: Cluster investigated and acted on.
Step 4. Review.
- Review the programme once a year against the data, incidents and national guidance, and approve the changes at governing body level.
Key point: Programme reviewed.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Hand hygiene compliance at the 5 Moments | 80% or more | Monthly | IPC lead | Retrain the area and repeat the audit within a month |
| Clusters with a recorded investigation and action | 100% | Quarterly | IPC lead | Escalate to the clinical director |
| Surveillance report produced | Every quarter | Quarterly | IPC lead | Escalate to the governing body |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- All staff complete infection prevention and control training at induction and every year, with a recorded competency check.
- The IPC lead completes advanced training every two years.
16. Related documents
| ID | Title | Use |
|---|---|---|
| HH-SOP-001 | Hand Hygiene at the Point of Care (existing) | SOP |
| HH-POL-001 | Hand Hygiene Policy (existing) | Policy |
| IPC-REG-001 | Healthcare-associated infection surveillance register (existing) | Register |
| PRO-SOP-005 | Sterile technique and infection control in procedures (existing) | SOP |
| SRG-POL-003 | Surgical site infection prevention (existing) | Policy |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
No e-learning course is linked to this document yet.
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)