Audit infection control and emergency planning for accreditation

What is going on

The accreditation survey is confirmed for 3 December and the Practice Manager wants the infection prevention and control evidence and the emergency planning evidence complete, with gaps fixed, by 6 November. Since March the incident register holds a failed steriliser load, a dental assistant sharps injury, a vaccine fridge excursion, a rejected unlabelled specimen and a privacy breach. Steriliser B has been out of service for two weeks. The credential register has staff with resuscitation and hand hygiene training near expiry. The Medical Emergency and Emergency Response Plan was updated this month and the drill is next week. You will present your findings and an action plan to the clinical governance committee on 14 October.

Your brief

Audit the infection control and emergency planning systems against the policies, procedures and the accreditation standards, analyse the incident register for themes, check credential currency, identify gaps with owners and due dates and present the findings and action plan to the clinical governance committee using the minutes template.

Work through it

You do not need to do it all. Doing a few of these will show you what the work is like. Your ticks and notes stay on this device.

• Read the Infection Prevention and Control Policy, the reprocessing procedure, the hand hygiene procedure and the Medical Emergency and Emergency Response Plan and build an audit checklist of the evidence each requires.
• Audit the Reprocessing and Steriliser Load Log for the last two weeks: confirm every load has contents, parameters, indicators, operator and release decision, and record every gap.
• Analyse the Clinical Incident and Hazard Register entries since March for infection, sterilisation, specimen and medication themes and check that each has actions and a closed loop.
• Check the credential register for hand hygiene, resuscitation and reprocessing competency currency and list every worker due within 60 days with the action required.
• Review the emergency plan against the standards: trolley checks recorded, drills scheduled at every site, roles known, and record any gap.
• Assess the steriliser B outage as a risk to service and to accreditation and propose a contingency and a decision for the committee.
• Write the action plan with each gap, the corrective action, the owner and the due date before 6 November, and enter the audit itself as a record in the incident register as a quality activity.
• Prepare the clinical governance committee minutes for 14 October using the template, recording the findings, decisions and actions.

What someone in this role would produce

• Audit checklist and completed audit worksheet
• Incident register theme analysis
• Credential currency list with actions
• Action plan with owners and due dates
• Draft clinical governance committee minutes