Infection Control Policies & Procedures

Question: What is the purpose of infection control policies and procedures?

Answer: In health care, policies and procedures describe protocols written, reviewed and adopted by the institution one is employed by. They are more than a guide, they define the expectations for performance and set standards that can and will be used to measure the appropriateness of the employee’s behaviors on the job. Whether documents are being created or revised, they must be accurate, consistent, compliant and based on current practice. Outdated policies must be updated at least annually and more often if warranted. 

The policies and procedures that most affect my position are those of the infection control manual. When a facility signs a contract to retain services from a lab and radiology company, they may be provided with an infection control manual that spells out policies and procedures for surveillance, tracking & trending, employee health, environmental issues, education etc.

Once a facility accepts the manual they should review it with their infection control committee; if they wish to adopt the policies and procedures, they must review, adopt, sign the Infection Control Committee Approval page, and rename the manual using the facility’s name. 

More often than not, the manual finds its way to the back of a book shelf  in some obscure office; Staff Developers and Directors of Nursing come and go, no one keeps up with the manual and eventually, many guidelines become outdated. 

Surveyors want to know facilities have an infection control program in place, that they have policies and procedures, and that they follow them. There are times when I receive an urgent call because a surveyor has surprised a facility and is asking questions they cannot answer; why? Because they are not familiar with the infection control manual and therefore, not familiar with their own policies and procedures. These facilities are at risk for being found deficient by surveyors.