Standards and Criterion of The Infection Control Standards Working Party


Hospital acquired infection remains an important, with approximately 10% of patients acquiring an infection during their hospital stay. The Infection Control Standards Working Party have identified five core standards, each of which is divided into criteria.

Standard 1 - Management structure and responsibilities in infection control

1. There is an infection control structure with sufficient resources and clear lines of responsibility - there should be an infection control committee (ICC) covering each provider unit, an infection control team (ICT) responsible for day to infection control, there are designated staff in outlying hospitals or small units who Liaise with the ICT. The Trust Chief Executive or Unit General Manager is ultimately responsible for providing resources.

2. The ICC consists of a chairperson, the Infection Control Doctor (ICD), the Consultant in Communicable Disease Control (CCDC), or Medical Officer for Environmental Health, Infection Control Nurses, Occupational Health Physician, Infectious Diseases Physician, a surgeon. a physician, chief nurse advisor and the Unit General Manager. Other members may include an engineer, pharmacist, HSDU manager. The ICC is responsible to the UGM and should meet at least twice a year to provide specialist advice, formulate and to monitor the implementation of policy. The chairperson is informed during a major outbreak of infection and decides when the ICC should meet.

3. The ICT comprises the ICD (usually a Consultant Medical Microbiologist), ICNs and has direct access to a representative of the Trust Chief Executive/UGM. The ICT is responsible to the ICC and directly to the Chief Executive. The ICT functions on a daily basis supported by adequate clerical staff. There should be at least one ICN who may liaise daily with the ICD. When a serious problem arises, the Chief Executive or representative is informed. The CCDC is informed of any significant hospital outbreak. In a serious outbreak, the CCDC informs the Regional Health Authority, the Chief Medical Officer, the CDSC and PHLS. The ICT must liaise closely with the CCDC and inform him of suspected cases of notifiable diseases or food poisoning. It is expected to provide advise on and monitor policies and procedures, conduct surveillance activity and review the effectiveness of control measures. When appropriate, an outbreak control group will be called.   

Standard 2 - Policies and Procedures

1. The ICC initiates the development, evaluation, and revision of written policies and procedures at least biennially. Reference is made to the appropriate legislation or published guidance. Each hospital department or service has a current copy of the approved policies and procedures pertinent to the activities of the department or service. Areas covered include;-

  1. Medical, surgical, nursing and physiotherapy procedures
  2. Isolation policies and procedures for high risk and communicable diseases
  3. Outbreaks of infection
  4. Mortuary procedures
  5. Sterile Supplies Services and decontamination of health care equipment
  6. Housekeeping, laundry, catering
  7. Engineering and building services, in particular ventilation and water services
  8. Building works
  9. Disposal of waste products
  10. Equipment purchasing e.g. reusable or disposable equipment


2. These policies and procedures are made known to the personnel, and there is an on going continuing education for employees working in high risk areas.

3. There should also be a written program for the auditing of infection control policies or procedure.    

Standard 3 - Microbiological Services

  1. A document is made available to all users of the laboratory which describes the organization and overall scope of the laboratory services.
  2. The laboratory is directed professionally by a consultant medical microbiologist or clinical scientist of equivalent status.
  3. The microbiology laboratory provides information and help relating to the control of infection within the hospital.
  4. Written policies are available relating to specimen collection, handling and disposal.
  5. There is a written policy for the reporting of results on each test ie. the circumstances in which verbal reports may be transmitted, and some indication as to when the report will be available.
  6. There is appropriate data storage, retrieval and communication facilities for laboratory and clinical information.

Standard 4 - Surveillance

  1. There are agreed objectives and priorities for surveillance of infection
  2. The methods of surveillance are defined and in place.
  3. There are mechanisms for storage, analysis, and distribution of surveillance data  

Standard 5 - Education

  1. Adequate resources are available in each unit for the necessary education facilities, such as the provision for annual study leave for ICN, purchase of books and audiovisual material, and facilities for study.
  2. An infection control educational program addresses topics of relevance to different types of health staff.
  3. The ICT is involved in the initial education of other health care personnel, such as the course design.
  4. There are mechanisms for the continuing education of health care staff.