Preventing and Controlling Healthcare-Associated Infection Standard

Evidence-based systems are used to mitigate the risk of infection. These systems account for individual risk factors for infection, as well as the risks associated with the clinical intervention and the clinical setting in which care is provided.

Infection Prevention and Control (IP&C) refers to evidence-based practices and procedures that, when applied consistently in healthcare settings, can prevent or reduce the risk of transmission of microorganisms to healthcare providers, clients, patients, residents and visitors.

The Healthcare Associated Infection (HAI) Program at the Clinical Excellence Commission (CEC) encompasses infection prevention and control and provides leadership in safety and quality in NSW to improve healthcare for patients.

The HAI program consists of a multidisciplinary team engaged in providing health professionals with expertise, support and resources for infection prevention and control.

There are several National and NSW resources available to support health service organisations meet National Standard 3 (NS3): Preventing and Controlling Infections.

National resources

NSW guidance for health service organisations

CEC resources

Integrating clinical governance

a. Establishes multidisciplinary teams to identify and manage risks associated with infections using the hierarchy of controls in conjunction with infection prevention and control systems.

b. Identifies requirements for, and provides the workforce with access to, training to prevent and control infections.

NOTE: see other policies, handbook and resource links throughout this document.

c. Has processes to ensure the workforce has the capacity, skills and access to equipment to implement systems to prevent and control infections.

  • Education, training, posters and videos
  • My Health Learning
    • Infection Prevention and Control Practices Course Code: 46777047
    • Infection Prevention and Control Principles Course Code: 48252740
    • Infection Prevention Strategies for Medical Officers Course Code: 111885084
    • Hand Hygiene Course Code: 42063430
    • Hand Hygiene Medical Course Code: 101378982

d. Establishes multidisciplinary teams, or processes, to promote effective antimicrobial stewardship.

e. Identifies requirements for and provides access to training to support the workforce to conduct antimicrobial stewardship activities.

f. Has processes to ensure the workforce has the capacity and skills to implement antimicrobial stewardship.

g. Plans for public health and pandemic risks

NOTE: see other policies, handbook and resource links throughout this document

Applying quality improvement systems

a. Monitoring the performance of infection prevention and control systems

b. Implementing strategies to improve infection prevention and control systems

c. Reporting to the governance body, the workforce, patients and other relevant groups on the performance of infection prevention and control systems

d. Monitoring the effectiveness of the antimicrobial stewardship program

Partnering with consumers


a. Incorporates national and jurisdictional information in a timely manner

b. Collects data on healthcare-associated and other infections relevant to the size and scope of the organisation

Standard and transmission-based precautions

a. Collaborative and consultative processes for the assessment and communication of infection risks to patients and the workforce

b. Infection prevention and control systems, in conjunction with the hierarchy of controls, in place to reduce transmission of infections so far as is reasonably practicable

c. Processes for the use, training, testing and fitting of personal protective equipment by the workforce

d. Processes to monitor and respond to changes in scientific and technical knowledge about infections, relevant national or jurisdictional guidance, policy and legislation

e. Processes to audit compliance with standard and transmission-based precautions

f. Processes to assess competence of the workforce in appropriate use of standard and transmission-based precautions

g. Processes to improve compliance with standard and transmission-based precautions

a. Patients' risks, which are evaluated at referral, on admission or on presentation for care, and re-evaluated during care

b. Whether a patient has a communicable disease, or an existing or a pre-existing colonisation or infection with organisms of local or national significance

c. Accommodation needs and patient placement to prevent and manage infection risks

d. The risks to the wellbeing of patients in isolation

e. Environmental control measures to reduce risk, including but not limited to heating, ventilation and water systems; workflow design; facility design; surface finishes

f. Precautions required when a patient is moved within the facility or between external services

g. The need for additional environmental cleaning or disinfection processes and resources

h. The type of procedure being performed

i. Equipment required for routine care

a. Review data on and respond to infections in the community that may impact patients and the workforce

b. Communicate details of a patient’s infectious status during an episode of care, and at transitions of care

c. Provide relevant information to a patient, their family and carers about their infectious status, infection risks and precautions and their duration to minimise the spread of infection

Hand hygiene

a. Is consistent with the current National Hand Hygiene Initiative, and jurisdictional requirements

c. Provides timely reports on the results of hand hygiene compliance audits, and action in response to audits, to the workforce, the governing body, consumers and other relevant groups

d. Uses the results of audits to improve hand hygiene compliance


  • Hand Hygiene Data

Aseptic technique

a. Identify the procedures where aseptic technique applies

  • Infection Prevention and Control Practice Handbook
  • b. Assess the competence of the workforce in performing aseptic technique

    c. Provide training to address gaps in competency

    • My Health Learning Course Code: 40027445

    d. Monitor compliance with the organisation's policies on aseptic technique

    Invasive medical devices

    Clean and safe environment

    a. Respond to environmental risks, including novel infections

    b. Require cleaning and disinfection using products listed on the Australian Register of Therapeutic Goods consistent with manufacturers' instructions for use and recommended frequencies

    c. Provide access to training on cleaning processes for routine and outbreak situations, and novel infections

    • My Health Learning - Environmental Cleaning Course Code: 45738936

    d. Audit the effectiveness of cleaning practice, and compliance with its environmental cleaning policy

    e. Use the results of audits to improve environmental cleaning processes and compliance with policy

    a. New and existing equipment, devices and products used in the organisation

    b. Clinical and non-clinical areas, and workplace amenity areas

    c. Maintenance, repair and upgrade of buildings, equipment, furnishings and fittings

    d. Handling, transporting and storing linen

    e. Novel infections, and risks identified as part of a public health response or pandemic planning

    Workforce screening and immunisation

    Infections in the workforce

    a. Are consistent with the relevant state or territory work health and safety regulation and the current edition of the Australian Guidelines for the Prevention and Control of Infection in Healthcare

    b. Align with state and territory public health requirements for workforce screening and exclusion periods

    c. Manage risks to the workforce, patients and consumers, including for novel infections

    d. Promote non-attendance at work and avoiding visiting or volunteering when infection is suspected or actual

    e. Monitor and manage the movement of staff between clinical areas, care settings, amenity areas, and health service organisations

    f. Manage and support members of the workforce who are required to isolate and quarantine following exposure to or acquisition of an infection

    g. Provide for outbreak monitoring, investigation and management

    h. Plan for, and manage, ongoing service provision during outbreaks and pandemics or events where there is increased risk of transmission of infection

    Reprocessing of reusable equipment and devices

    a. Processes for reprocessing that are consistent with relevant national and international standards, in conjunction with manufacturers’ guidelines

    b. A traceability process for critical and semi-critical equipment, instruments and devices that is capable of identifying
    − the patient
    − the procedure
    − the reusable equipment, instruments and devices that were used for the procedure

    c. Processes to plan and manage reprocessing requirements and additional controls for novel and emerging infections

    Presentation on AS/NZS4187:2014 – how to prepare for accreditation

    AS/NZS 4187:2014 Audit for CSD and Endoscopy

    AS/NZS 4187:2014 Audit for satellite sites

    AS/NZS 4187:2014 Audit for Oral/Dental Health Services

    Resources to register ultrasound probes and reprocessing areas

    The CEC have produced two registers to assist with health facilities to register the location of reprocessing areas and ultrasound probes. These registers are located in QARS for NSW public health facilities.

    My Health Learning

    Decontamination of reusable medical devices Course Code:46357618

    Antimicrobial stewardship

    a. Includes an antimicrobial stewardship policy

    b. Provides access to, and promotes the use of, current evidence-based Australian therapeutic guidelines and resources on antimicrobial prescribing

    c. Has an antimicrobial formulary that is informed by current evidence-based Australian therapeutic guidelines or resources, and includes restriction rules and approval processes

    d. Incorporates core elements, recommendations and principles from the current Antimicrobial Stewardship Clinical Care Standard

    e. Acts on the results of antimicrobial use and appropriateness audits to promote continuous quality improvement

    a. Review antimicrobial prescribing and use

    b. Use surveillance data on antimicrobial resistance and use to support appropriate prescribing

    c. Evaluate performance of the program, identify areas for improvement, and take action to improve the appropriateness of antimicrobial prescribing and use

    d. Report to clinicians and the governing body regarding

    • compliance with the antimicrobial stewardship policy and guidance
    • areas of action for antimicrobial resistance
    • areas of action to improve appropriateness of prescribing and compliance with current evidence based Australian therapeutic guidelines or resources on antimicrobial prescribing
    • the health service organisation’s performance over time for use and appropriateness of use of antimicrobials