The Chief Executive has overall responsibility for infection prevention and control, on behalf of the Board of Directors of the Trust. In addition, the Chief Executive is responsible for ensuring that the Trust is in a position to provide an overall assurance that the organisation has in place the necessary controls to manage its infection prevention and control.
In order to make such a statement, the Chief Executive and Board of Directors will need to provide evidence that the Trust’s Infection Prevention and Control Strategy is being implemented with systems and processes being regular reviewed and that, where deficiencies are identified, developments and improvement mechanisms are being put in place with the overall aim of continuous improvement.
A Non-Executive Director with a delegated responsibility for infection prevention and control sits on the Board and provides regular reports to the Trust Board of the organisation’s progress with the infection prevention and control.
Specific responsibilities are delegated to members of the Executive team as follows:
The Nursing and Patient Services Director has delegated responsibility to ensure the implementation and further development of the Infection Prevention and Control Strategy.
The Medical Director has delegated responsibility to support the implementation and further development of the Infection Prevention and Control Strategy.
The Finance Director, Business Director and Operations and Development Director all share in the overall corporate responsibility to support the implementation and further development of the Infection Prevention and Control Strategy.
The Director of Infection Prevention and Control has specific responsibilities to advise the Board on all issues relating to Infection Control.
The Assistant Director-Quality will support the Directors of the Trust with implementation and development of this Strategy. The Assistant Director-Quality will be responsible for ensuring the integration of infection prevention and control with corporate clinical governance departments and systems, with the aim of developing and improving reporting, analysis and learning on all aspects of clinical governance and risk including health and safety, litigation and claims, and complaints.
The Nurse Consultant for Infection Control will provide specialist knowledge and advice on all matters pertaining to infection control. The Nurse Consultant is responsible for:
- All areas of infection control in relation to the production, review and implementation of local policies, protocols and guidelines with input from other appropriate clinical and non clinical staff
- Leading the Saving Lives Campaign
- Leading the Infection Prevention and Control Audit Programme
- Developing and maintaining partnership working with other Infection Control Specialists, partner organisations and patient groups across the region.
Clinical Directors, Matrons and Directorate/Department Managers
Directorate Management Teams will be responsible for ensuring that the Infection Prevention and Control Strategy is implemented effectively across all services, which will include:
- dissemination of the Strategy details and allocation of responsibilities for implementation to service managers and staff
- identifying directorate specific infection control issues that might not have been addressed explicitly within the Strategy
- ensuring that infection prevention and control is incorporated into the Directorate/Department decision-making, service planning, performance management, project management and other related processes
- establishing key infection control risk indicators which are monitored, reviewed and reported on a regular basis
- ensuring that there are effective Healthcare Associated Infection Prevention and Control processes in place in accordance with the Action Plan and that the appropriate level of local management action is initiated and completed
- ensuring that infection prevention and control is included as a core item on all management team briefings/meetings
- introducing infection prevention and control targets for managers as part of the performance and development appraisal process
- reporting via performance and clinical practice and standards reviews on the Directorate infection prevention and control management performance in addition to new and emerging risks, major changes of priority on existing risks and key actions
- ensuring that, where necessary, healthcare associated infection prevention and control risks are reported on the Risk Register.
In addition to contributing to the responsibilities as outlined above, Matrons will have responsibility for:
- leading and driving a culture of cleanliness in clinical areas
- identification of healthcare associated infection prevention and control training needs to ensure that staff and volunteers are able to work safely and comply with Trust procedures, including mandatory training requirements
- ensuring implementation of Trust healthcare associated infection prevention and control policies and procedures
- ensuring that there is promotion of healthcare associated infection prevention and control awareness responsibilities amongst employees, service users, contractors and partners
- introducing infection prevention and control targets
- leading Root Cause Analysis where required to promote learning and practice improvement
- ensuring effective ward management by Sisters and Charge Nurses, which includes implementation of infection prevention and control policies, the provision of high standards of essential patient care and the maintenance of a safe clean and patient friendly environment
- monitoring standards of cleanliness in clinical areas.
Directorate/Department Clinical Governance Leads
The Clinical Governance Lead will support the Directorate/Department Management Team in the delivery of effective healthcare associated infection prevention and control practice, education, audit and learning.
Infection Control Link Healthcare Professional
The Link Healthcare Professionals role is to act as a facilitator of good practice in infection control within their area of work. The link professional will:
- attend infection control link meetings and feedback the information gained to colleagues
- act as a resource to staff in their area of work
- participate in standard setting and audit.
Responsibilities of all employees Clinical & Non Clinical (including temporary staff)
All staff have a responsibility to ensure patient safety through the implementation of the best possible infection prevention and control practice.
As an employee of the Trust, everyone has a responsibility for and a role to play in managing infection prevention and control, which includes:
- Being aware of Trust infection prevention and control policy and procedure
- Adhering to infection prevention and control as required within their job
- Alerting managers to any infection control risks or environmental deficits within the service area that requires urgent attention
- Participation in annual mandatory infection prevention and control training
- Maintaining a clean and safe environment.
As the ethos of the Trust Risk Management Strategy is to develop an environment where the focus and culture is on reporting and learning from mistakes and near misses, formal disciplinary action will not usually be taken as a result of an infection control incident. However a serious breach of infection control policy or negligence causing loss or injury will be regarded as gross misconduct and will be considered within the Trust Disciplinary Procedure Policy. Disciplinary action may ensue where it is found that a member of staff has acted maliciously or recklessly.
Author: Nursing & Patient Services Director 2008