DEPARTMENTAL POLICY AND PROCEDURES

INFECTION CONTROL DEPARTMENT

Title
LOGO
COMMITTEE AND MEETINGS (Infection Control)

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Dr. Albar Medical IC Committee
Hospital Effective Date: Review Date:

1. PURPOSE
a. To establish a system that is well coordinated and organized in order to supervise the
infection control activities of the Health Care workers and other ancillary services of Dr. Albar
medical Hospital.
2. DEFINITION
a. The committee is composed of Heath Care Workers represented by the different departments
of the hospital as its members to form the Infection Control Committee.
3. RESPONSIBILITIES

ICD STATEMENT OF AUTHORITY – Acting through the Hospital Director, the Infection Control
Committee has the authority to:

a. Implement the policies and procedures within the hospital in matters of Infection Control.
b. It has the authority to investigate potential or real episodes of serious hospital acquired
infections and, where necessary, to close wards and redirect patients.
c. It has the authority to formulate the infection control team within the hospital.
d. Education and orientation program for professional staff.
e. Surveillance of employees’ health.
f. Standards of hospital domestic cleaning and food hygiene.
g. Management of visitors in isolation circumstances.
h. Establish and supervision of the Infection Control Team.
i. Submit activity report and statistical data to the MOH as required.
j. Recommend policies for the prevention of Hospital Acquired Infection and ensure that they
are implemented.
k. Maintain records on surveillance, outbreaks, needle stick injury incidents. These are compiled
by the Infection Control Team and come up for discussion during the meetings.
l. Formulate an antibiotic policy based on the needs of the different specialties and prevalent
susceptibility patterns.
m. Implement policies for the safety of health care workers.
n. Regulate and give recommendations on any construction or renovation work in the hospital.
The plan should be approved by the committee.
o. Discuss and find solutions to problems related to infection control encountered by different
doctors in their specialties.
4. POLICY
a. The Infection Control Committee meeting is chaired by the Hospital Director/Designee.

Prepared by: Reviewed by: Reviewed by:

STAMP

Approved by: Approved by: Approved by:

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COMMITTEE AND MEETINGS (Infection Control) IC Committee

b. The Infection Control Committee conducts its meetings ___________________.

c. Members are represented by different departments of the hospital.
d. Each member is issued letters of appointment signed by the Authority.
5. PROCEDURE
a. The venue of the meeting is held at the conference room every _________________________
_____________________.
b. The meeting usually is done for one hour (________ to _________), but extends the times as
needed.
c. Pocket of the meeting is given to all members of the committee as soon as statistical reports
are ready. Pocket of the meeting will include:
i. Agenda
ii. Minutes of the previous meeting
iii. Nosocomial statistics for the quarterly months.
iv. Communicable and Reportable Disease Reports and statistics.
d. Members who cannot attend the meeting should be represented by his/her designee.
e. ICC Members
i. Hospital Director (ICC Chairman)
ii. Assistant Hospital Director
iii. Quality Management Director
iv. Medical Director
v. Chief Operating Officer
vi. Chief Microbiologist
vii. Nursing Service
viii. Pharmacist
ix. CSSD and Laundry
x. Kitchen
xi. OR Supervisor
xii. ICU and NICU Head
xiii. Housekeeping and Maintenance
xiv. Infection Control Director
xv. Infection Control Coordinator
xvi. Infection Control Practitioners
xvii. Safety Committee
xviii. Supplies Department
xix. Mortuary Department
f. Absence of the members shall be minuted and monitored
g. The ICC secretary will document the minutes of the meeting
h. Approved minutes of the meeting is given to the Hospital Supervisor and the ICC Members
6. CROSS REFERENCE
7. FORMS
a. Committee Formation order
b. Agenda Distribution List
c. Minutes of the meeting (vacant form)
d. Monthly Hospital Nosocomial rates (vacant form)

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COMMITTEE AND MEETINGS (Infection Control) IC Committee

8. MATERIALS
9. CBAHI REFERENCE STANDARD
a. IC. 5, IC, 6
10. REFERENCE
a. MOH Infection Control Manual (General Directorate, K.S.A. 1408)
b. Hospital Infection Control Manual (Directorate of Medical Education, Thirunanthapuram,
Kerala, India)

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