The infection prevention and control chapter generates more document requests during a survey than any other. This is the set that keeps coming up.
Programme level
- Infection prevention and control programme with annual goals and a risk assessment
- Surveillance plan naming the indicators (CLABSI, CAUTI, SSI, VAP), the definitions and the reporting cadence
- Antimicrobial stewardship policy with the restricted list and the approval workflow
Practice level
- Hand hygiene policy following the WHO five moments, plus the observation form
- Isolation precautions policy with the transmission-based categories and the signage
- Cleaning, disinfection and sterilisation procedures per area and per device class
- Healthcare waste segregation procedure with the colour code and the manifest form
- Occupational exposure and needle-stick procedure with the post-exposure form
What surveyors check between documents
- The definitions in the surveillance plan match the ones used on the KPI charts.
- The restricted antimicrobials in the AMS policy match what the pharmacy actually enforces.
- The hand hygiene compliance target in the programme equals the target on the dashboard.
Consistency is easier when one team owns the set and every document cites the standard it serves. Generating the set from a single facility profile keeps department names, committees and frequencies identical across all of them.