Standards › Standard S1 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · HOS-SOP-014 · Version 1.0 · Approved by the ASF Expert Committee
Supports: System S1 (Hospital), criterion S1.18
At a glance
- Count healthcare-associated infections every month by type and ward.
- Review the rates every quarter.
- Act on any rise with an investigation and an action.
- Report the results to the governance meeting.
- Stop and get help straight away if: no monthly infection count has been recorded for two months.
1. Purpose
To track healthcare-associated infections over time and act when they rise (S1.18). Based on WHO core components of IPC programmes.
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 |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Healthcare-associated infections are common and often preventable. Tracking the rate over time shows whether prevention works.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Infection prevention and control lead | Runs surveillance and reports | Infection control |
| Ward manager | Reports infections; acts on rises | Nurse manager |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Surveillance register (HOS-REG-005) | Current | Updated monthly |
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. Count.
- Record each infection with type, ward and date, using the agreed definitions.
Key point: Same definitions every month.
Step 2. Review.
- Calculate the rates each quarter and compare with the previous year.
Key point: Trends matter more than single months.
Step 3. Respond to a rise.
- Investigate the cause.
- Agree an action with an owner and a date.
Key point: A rise without an action is not acted on.
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 |
|---|---|---|---|---|
| Monthly counts recorded | 100% | Monthly | Infection prevention lead | Escalate to chief executive |
| Rises with an action | 100% | Quarterly | Infection prevention lead | Escalate to governance |
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
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| HOS-REG-005 | Healthcare-associated infection surveillance register | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-002 | WHO Core components of IPC programmes (2016). |
| 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 |
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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)
- World Health Organization (2016). Guidelines on Core Components of Infection Prevention and Control Programmes at the National and Acute Health Care Facility Level. Geneva: WHO. Open source (E-002)