Service Standard 05 Prevention and Control of Infection

MSQH Malaysian Hospital Accreditation Standards & Assessment Tool 6th Edition 2021
SURVEY ITEM &SELF-ASSESSMENT
SERVICE STANDARD 5 : PREVENTION AND CONTROL OF INFECTION
PREAMBLE
These standards are applicable to affect facility-wide Prevention and Control of Infection Services. The aim of the service is to identify and minimize
the risks and development of healthcare associated infection, the emergence of antimicrobial resistance and the transmission of these infection
among patients, families, healthcare providers, staff of contracted services, students, and visitors.
Adherence to the current national and international health policies, procedures and regulatory requirements are necessary to improve prevention
and control of healthcare associated infections. Preventing the spread of antimicrobial resistance also requires appropriate and responsible use of
antimicrobials
TOPIC 5.1: ORGANISATION AND MANAGEMENT
STANDARD The Prevention and Control of Infection (PCI) Services and Antimicrobial Stewardship Services (AMS) are organised and administered to provide
5.1.1 optimum support to the Vision, Mission, goals and objectives of the Facility, towards the implementation of safe infection control practices in line
with current national and international health policies, procedures and regulatory requirements.
SURVEYOR FINDINGS
SELF
CRITERIA FOR COMPLIANCE:
RATING AREAS FOR IMPROVEMENT / SURVEYOR
RECOMMENDATIONS & RISK ASSESSMENT RATING
5.1.1.1 Vision, Mission and values statements of the Facility are accessible. Goals and
objectives that suit the scope of the Prevention and Control of Infection Services and
Antimicrobial Stewardship Services are clearly documented and measurable that
indicates safety, quality and patient centred care. These reflect the roles and aspirations
of the service and the needs of the community. These statements are monitored,
reviewed and revised as required accordingly and communicated to all staff.
SERVICE STANDARD 5 – PREVENTION AND CONTROL OF INFECTION Page 1 of 25

1. Vision, Mission and values statements of the Facility are

available, endorsed and dated by the Governing Body.
2. Goals and objectives of the Prevention and Control of Infection
Services and Antimicrobial Stewardship Services in line with
the Facility statements are available, dated and endorsed.
EVIDENCE OF
COMPLIANCE
3. Evidence of planned reviews of the above statements.
4. These statements are communicated to all staff (orientation
programme, minutes of meeting, etc)
5. Achievement of goals and objectives are monitored, reviewed
and revised accordingly
Facility Comments:
5.1.1.2 There is an organisation chart which:
a) provides a clear representation of the structure and functions of the Facility’s

Hospital Infection and Antibiotic Control Committee (HIACC) and the reporting
relationships of the PCI Team and AMS Team to the HIACC.
b) is accessible to all relevant staff in PCI and AMS.
c) is revised when there is a major change in any of the following:
i). organisation.
ii). functions.
iii). reporting relationships.
iv). staffing patterns.
1. Clearly delineated current organisation chart with line of

functions and reporting relationships.
EVIDENCE OF
COMPLIANCE
2. Organisation chart of the services endorsed, dated and

accessible.
3. The organisation chart is revised when there is a major
change in any of the items (c)(i) to (iv).
Facility Comments:
5.1.1.3 There is a Hospital Infection and Antibiotic Control Committee (HIACC) chaired by a
CORE medical practitioner with knowledge of and special interest in infection control and
antimicrobial stewardship. The HIACC consists of members from multidiscipline

(medical, nursing and clinical support services, and by invitation administration and any
other relevant staff). The committee has:
a) Appointment of a Chairperson
b) Terms of Reference
c) Committee members
d) Tenure of membership
e) Frequency of meetings
1. Establishment of HIACC
2. Appointment letters of committee members
EVIDENCE OF
COMPLIANCE
3. Terms of Reference
4. Minutes of meeting
5. Qualification of Chairperson
Facility Comments:
5.1.1.4 The Prevention and Control of Infection (PCI) Team and Antimicrobial Stewardship
CORE (AMS) Team has a working relationship and reports to the HIACC. The PCI Team shall
be headed by Infection Control Doctor Coordinator and assisted by trained and Infection
Control Nurses.
The AMS Team shall be headed by AMS Coordinator and assisted by trained and
related personnel in AMS activities.
1. Appointment letters of
• PCI Unit/Team member
EVIDENCE OF COMPLIANCE
• AMS member
2. Terms of Reference for PCI/AMS Team members

3. Infection control activities reports and discussion
4. Antimicrobial stewardship activities reports and discussion
Facility Comments:

5.1.1.5 The link nurse/link personnel act as a link between the staff in the ward/service units and
the infection control team while the link ward pharmacists act as a link between the staff
in the ward/service units and the antimicrobial stewardship team.
1. Appointment letters for link nurses/link personnel
2. Description of duties and responsibilities for link nurses/link
personnel
3. Appointment letters for link ward pharmacist
4. Description of duties and responsibilities for link ward
pharmacists
Facility Comments:
5.1.1.6 HIACC meetings shall be held at least once in every 6 month and whenever necessary
CORE to discuss issues matters pertaining to the operations of the PCI services and AMS
relevant activities. Minutes are kept; decisions and resolutions made during meetings
shall be accessible, communicated to all staff of the service and implemented.
1. Minutes are accessible, disseminated and acknowledged by
the members
2. Attendance list of members with adequate representatives of
COMPLIANCE
EVIDENCE OF
the committee
3. Frequency of meetings as scheduled.
4. Discussion and resolutions are implemented (Problems not
solved to be brought forward in the next meeting until resolved).
Facility Comments:
5.1.1.7 The Chairman of HIACC and / or the Head of Prevention and Control of Infection (PCI),
is involved in planning, justification and management of budget and resource utilisation
of the services.
1. Minutes of HIACC meeting
2. Minutes of facility-wide management meeting
EVIDENCE OF
COMPLIANCE
3. Documented evidence on request for allocation of budget and

resources (staffing, equipment, etc) for the service – if
applicable

4. Approved budget and resources – if applicable
Facility Comments:
5.1.1.8 The Head of PCI services and AMS relevant activities. is involved in the assignment of
staff.
1. Assignment letter of Head of PCI/AMS

2. Job description of Head of PCI/AMS

3. Records on staff deployment PCI/AMS
4. Duty roster
• PCI
• AMS
Facility Comments:
5.1.1.9 Appropriate statistics and records shall be maintained in relation to the provision of PCI
Services and AMS relevant activities and used for managing the services and patient
care purposes.
1. Records are available but not limited to the following:

a) surveillance reports – laboratory based and clinical based;
b) audit reports, e.g. environment, etc
c) antibiotic resistance pattern;
EVIDENCE OF
COMPLIANCE
d) incident reports;
e) staffing number and staff profile;
f) staff training records;
g) data on performance improvement activities, including
performance indicators.
h)
antimicrobial usage data of broad spectrum antibiotics (eg
Carbapenems, Vancomycin
Facility Comments:

5.1.1.10 Where more than one committee have interests in the issues of the PCI services and
AMS relevant activities, there is evidence of coordination of the actions undertaken or
proposed by the committees. Records are kept on actions taken to identify and correct
the cause of any problem.
1. Minutes of committee meetings, e.g. Health and Safety

EVIDENCE OF
Committee, Operating Theatre Committee, Equipment
COMPLIANCE Procurement Committee, etc.
Facility Comments:
5.1.1.11 There are safety measures taken to ensure the protection of the Facility’s staff and
environment against healthcare associated infections. Records shall be kept on action
taken which include:
a) staff education;
b) staff health screening including infectious diseases;
c) staff immunisation;
d) staff health record maintenance;
e) provision for adequate and good quality personal protective equipment (PPE);
f) implementation of safety devices;
g) clinical waste management;
h) protocol for post-exposure management for infectious disease and for assignment
of infected staff.
1. Where appropriate, records are kept on actions taken which

include items (a) to (h).
EVIDENCE OF
COMPLIANCE
Facility Comments:

5.1.1.12 Provision is made for the personal comfort and safety of patients and staff which include:
a) clean and hygienic facilities;

b) room temperatures are kept at comfortable levels;
c) disinfection and sterilisation areas; safe equipment and instruments;
d) proper hand hygiene facilities;
e) aseptic techniques for procedures;
f) practice of standard and transmission-based precautions;
g) adequate PPE supplies;
h) appropriate well ventilated facilities
1. There is evidence of items (a) to (h) being implemented.

EVIDENCE OF
COMPLIANCE
Facility Comments:

TOPIC 5.2 HUMAN RESOURCE DEVELOPMENT AND MANAGEMENT
STANDARD The PCI Services shall be staffed by adequate numbers of appropriately qualified, trained and certified staff to achieve the goals and objectives of
5.2.1 the service. These designated staff shall maintain competency through Continuing Professional Development (CPD).
SURVEYOR FINDINGS
SELF
CRITERIA FOR COMPLIANCE: AREAS FOR IMPROVEMENT / SURVEYOR
RATING
5.2.1.1 The Head and staff of the PCI services and AMS relevant activities. shall be individuals
qualified by education, training, experience and certification to commensurate with the
requirements of the various positions.
1. Records on credentials of Head of Service/Team and staff

required to fill up the posts within the service (to match the
complexity of the Facility and services).

2. Assignment letters
3. Certification
4. Training and competency records including privileging (for PCI
& AMS)
Facility Comments:
5.2.1.2 The authority, responsibilities and accountabilities of the Head of PCI services and AMS
relevant activities. are clearly delineated and documented.
1. Appointment/assignment letter for Head of Service

EVIDENCE OF
COMPLIANCE
2. Description of duties and responsibilities.
Facility Comments:

5.2.1.3 The infection control nurse (ICN) shall have post basic/advanced diploma infection
CORE control training and certified.
The AMS pharmacist shall have attended the AMS pharmacist training program and be
certified.
1. PCI - Post basic /advanced diploma infection control

qualification.
EVIDENCE OF
COMPLIANCE 2. AMS – AMS pharmacist has AMS pharmacist training
program
Facility Comments:
5.2.1.4 The head of PCI Services/Team is responsible for the effective implementation of
infection control policies and activities
The head of AMS services/team is responsible for the effective implementation of
antimicrobial stewardship policies and activities
1. Surveillance/audit reports and records
2. Environmental inspection records
EVIDENCE OF
COMPLIANCE
3. On-site training records conducted by

• ICN in-charge
• AMS trained pharmacist
Facility Comments:
5.2.1.5 Sufficient numbers of personnel and support staff including link nurses/link personnel
CORE and link pharmacists with appropriate qualifications are employed to meet the need of
the services according to national norms
1. Full time staff (Infection Control Nurse) in accordance with
national norm commensurate with bed occupancy rate.
2. Appointed pharmacist (AMS trained, when available)

3. Availability of in each ward/unit.
• link nurses/link personnel
• ward pharmacist (where applicable)
4. Census and statistics
Facility Comments:

5.2.1.6 There are written and dated specific job descriptions for members of PCI services and
AMS relevant activities. that include:
a) qualifications, training, experience and certification required for the position;
b) lines of authority;
c) accountabilities, functions and responsibilities;
d) reviewed when required and when there is a major change in any of the
following:
i). nature and scope of work;
ii). duties and responsibilities;
iii). general and specific accountabilities;
iv). qualifications required and privileges granted;
v). staffing patterns;
vi). Statutory Regulations.
e) administrative and clinical functions.
1. Updated specific job description is available for each staff that
includes but not limited to as listed in (a) to (e).
2. Job description includes specialisation skills

3. Relevant privileges granted where applicable
4. The job description is acknowledged by the staff and signed
by the Head of Service/Team and dated.
Facility Comments:
5.2.1.7 There is a structured orientation programme where new PCI services and AMS relevant
activities. members are briefed on their services, operational policies and relevant
aspects of the Facility to prepare them for their roles and responsibilities.
1. Policy requiring all new team members to attend structured

orientation programme.
2. Records on structured orientation programme
3. Orientation module
4. List of attendance
Facility Comments:

5.2.1.8 There is evidence of training needs assessment and staff development plan which
provide the knowledge and skills required for staff to maintain competency in their
current positions and future advancement.
1. Training needs assessment is carried out and gaps identified.

2. A staff development plan based on training needs assessment
EVIDENCE OF
COMPLIANCE
is available.
3. Training schedule/calendar is in place.
4. Training module.
Facility Comments:
5.2.1.9 There are continuing education activities for staff to pursue professional interests and to
prepare for current and future changes in practice.
1.
Training calendar includes in-house/external courses/
workshop/conferences.
2. Contents of training programme.
3. Training records on continuing education activities are kept
and maintained for each staff.
4. Certificate of attendance/degree/advanced diploma/post
basic// training.
Facility Comments:
5.2.1.10 There is evidence that all PCI staff have the opportunity to attend additional training in
the conduct of procedures unique to the services such as the operating rooms,
obstetrical units, emergency services, special care units, Central Sterilising Supply
Services and isolation rooms etc.
1. Training records on prevention of healthcare associated
infections and the roles of the staff in specialised areas.
EVIDENCE OF
COMPLIANCE
2. Training on safety measures in high risks areas such as the

central sterilising supply services, operating theatres, scope
rooms, critical care areas, immunocompromised patient areas,
kitchens, laundry, laboratories and radiation emission areas etc.
Facility Comments:

5.2.1.11 The PCI services and AMS relevant activities. are involved in orientation and in-service
CORE education for all staff including medical practitioners, house officers, students,
volunteers, staff of contracted services, family members and patients where appropriate.
1. Facility-wide orientation programme

• PCI
• AMS
2. Link nurses/link personnel orientation programme
3. Pharmacist orientation program
4. Outsourced services’ staff orientation programme
• PCI
5. Patient and family members orientation checklist
• PCI
Facility Comments:

TOPIC 5.3: POLICIES AND PROCEDURES
STANDARD Documented policies and procedures shall reflect the current knowledge on prevention and practice of infection control services, and they are
5.3.1 consistent with the goals and objectives of the services and relevant regulations and statutory requirements.
SURVEYOR FINDINGS
SELF
RATING
5.3.1.1 There are written policies and procedures for the PCI services and AMS relevant
CORE activities. relevant to the scope of services, complexity of the Facility and level of risks
consistent with national and international requirements. These policies and procedures
are signed, authorised and dated.
There is a mechanism for an evidence of a periodic review at least once in every three
years. Update on relevant topics shall be made earlier if required.
1. Facility-wide infection control policies and procedures which are

customised to the complexity of the services provided. The policies and
procedures address the following:
a) preventive and control procedures for all aseptic
techniques and practices related to sterilisation and
disinfection;
b) fight against antimicrobial resistance;

c) use of personal protective equipment (PPE);
d) healthcare associated infection and isolation (patients and
visitors);
e) central sterilising supply services;
f) housekeeping services;
g) laundry services;
h) food handling;
i) handling of sharps and waste;

j) pharmacy services;
k) surgical and nursing procedures;
l) pathology services;
m) engineering services;
n) ventilation system;
o) facility and equipment maintenance, and all others.
2. Facility-wide Antimicrobial policy which are customised to the complexity
of the services provided. The policies should, as a minimum, address the
following:
a) Objectives of the policy
b) AMS Principles of antimicrobial usage in the facility (eg
documentation of indication for the antimicrobial
prescribed)
c) Hospital Antimicrobial formulary
d) List of restricted antimicrobials
e) Approval processes for restricted antimicrobials
f) Any Quality Improvement initiatives planned to improve
antimicrobial prescribing in the facility
3. Current Ministry of Health Policies and Procedures on Infection
Control are available for reference (updates).
4. An AMS protocol that is available for reference. (e.g. Ministry
of Health Protocol on Antimicrobial Stewardship in Healthcare
Facilities)
5. Evidence of periodic review of policies and procedures.
6. The policies and procedures are endorsed and dated.
Facility Comments:
5.3.1.2 Policies and procedures are developed by a committee in collaboration with various
disciplines involving representatives from medical practitioners, pharmacy, nursing,
management, engineering and where required with other external service providers and
with reference to relevant sources involved.

Cross departmental collaboration is practised in developing relevant policies and

procedures where applicable.
1. Minutes of committee meetings on consultation with PCI teams
EVIDENCE OF
COMPLIANCE
when planning relevant policies (eg OT committees, OSH)
Facility Comments:
5.3.1.3 Current guidelines, policies and procedures are communicated to all facility staff.
1. Training and briefing on the current policies and

procedures/Minutes of meetings.
EVIDENCE OF
COMPLIANCE
2. Circulation list and acknowledgement.
Facility Comments:
5.3.1.4 There is evidence of compliance with policies and procedures and evidence based
CORE guidelines (World Health Organization/ Centres for Disease Control and
Prevention/Ministry of Health) as stated in 5.3.1.1.
1. Infection control practices (on-site observation) in each of the

areas mentioned (5.3.1.1).
2. Audit reports on infection control practices
3. Healthcare associated infection outbreak investigations and
reports investigated and reported investigations and reports
EVIDENCE OF
COMPLIANCE
4. Staff health status report on cases related to infection control

5. Compliance with National or local antibiotic guidelines.
6. Data collection on Antimicrobial resistance reports
7. Data collection on usage of broad spectrum or restricted
antimicrobials
Facility Comments:
5.3.1.5 Copies of policies and procedures, protocols, guidelines, relevant Acts, Regulations,
By-Laws and statutory requirements are accessible to staff.

1. Copies of policies and procedures, protocols, guidelines,
EVIDENCE OF
relevant Acts, Regulations, By-Laws and statutory
COMPLIANCE
requirements are accessible on-site for staff reference.
Facility Comments:
5.3.1.6 Current reference manuals, pamphlets, journals, and books as well as information and
scientific data concerning infection control and antimicrobial stewardship shall be
available for reference and guidance.
1. Copies of relevant documents for reference and guidance.

EVIDENCE OF
COMPLIANCE
Facility Comments:
5.3.1.7 Regular “environmental infection risks” (e.g. air, water and surface environment)
inspections are conducted throughout the Facility for the purpose of quality improvement
and the updating policies and procedures related to infection control practices.
1. Report/documentation on infection risks environmental

EVIDENCE OF
COMPLIANCE
inspections (e.g. air, water and surface environment)

2. Corrective and preventive actions taken, e.g. training,
improvement of infection control practices and other activities.
Facility Comments:
5.3.1.8 The PCI Unit/Team shall be consulted in order to ensure that:

a) proposed demolition, building constructions and renovations are designed in line
with accepted infection control requirements.
b) proposed new equipment (critical and semi critical medical devices) intended for
patient care conforms to accepted infection control standards.

1. Records on input from PCI Unit/Team for (a) and (b) where
EVIDENCE OF
COMPLIANCE
applicable.
Facility Comments:
5.3.1.9 The HIACC reviews reports on healthcare associated infections rates, surveillance
CORE studies of infections and infection potentials, and the implementation of infection control
and antimicrobial stewardship policies. Pertinent findings shall be submitted to the
appropriate source for necessary action.
1.
Minutes of HIACC meeting
2.
Reports on: -
a) healthcare associated infection rates;
b) surveillance data on infections and infection potentials;
EVIDENCE OF
COMPLIANCE
c) implementation of infection control policies.

d) Antimicrobial usage of broad spectrum and restricted
antimicrobials
e) Any pertinent relevant report (e.g outbreak report)
3. Records on pertinent findings submitted to the appropriate
source for necessary action to be taken.
Facility Comments:
5.3.1.10 Policies and procedures for infectious patients and those requiring isolation and
treatment are available and complied including the following:
a) proper isolation of infectious cases based on mode of transmission.
b) hand hygiene practices.
c) the isolated patients receive the same quality of care as is provided throughout
the Facility.
1. Documented policies and procedures include (a), (b) and (c).
2. Patient’s orientation checklist (briefing on infection control
EVIDENCE OF
COMPLIANCE
practices)
3. Records on implementation of (a), (b) and (c)
4. Validation upon on-site inspection of items (a), (b) and (c).
Facility Comments:

TOPIC 5.4: FACILITIES AND EQUIPMENT
STANDARD Adequate facilities and equipment are available to prevent and control the risks of infection throughout the Facility including disinfection and
5.4.1 sterilisation areas.
SURVEYOR FINDINGS
SELF
RATING
5.4.1.1 There are adequate and appropriate facilities and equipment with proper utilisation of
space for disinfection and sterilization process. patient management to enable staff to
carry out their professional and administrative functions.
1. Adequate and proper utilisation of space
2. Space for admin functions
EVIDENCE OF
COMPLIANCE
3. Appropriate type of equipment to match the complexity of

services and to prevent and control the risks of infection.
4. Easy access and clear exit routes
Facility Comments:
5.4.1.2 The use of all medical devices and disinfectants shall comply with the manufacturers’
CORE instructions on prevention and control of infection.
1. Manufacturers’ instructions on medical devices and
disinfectants for prevention and control of infection are in place
for reference.
EVIDENCE OF
COMPLIANCE
2. Material Safety Data Sheet (MSDS) for chemical used is

available.
3. Records and observation on practices.
Facility Comments:

5.4.1.3 Where single use devices or instruments are to be reused, the processes for
reprocessing are consistent with relevant international standard.
1. Policy on reprocessing of single use devices.
EVIDENCE OF
COMPLIANCE
2. Observation on practice upon on-site inspection
Facility Comments:
5.4.1.4 Adequate personal protective equipment (PPE) shall be provided for healthcare
providers, patients and visitors where appropriate.
1. Records on requests and supplies of PPE
EVIDENCE OF
COMPLIANCE
2. Observation on practice upon on-site inspection
Facility Comments:
5.4.1.5 Isolation facilities for patient requiring transmission-based precaution of airborne

infection and immunocompromised patients shall comply with regulatory requirements.
1. Isolation rooms available with negative or positive pressure
EVIDENCE OF
COMPLIANCE
gauge monitoring and airlock with PPE facilities.
2. Record of maintenance shall be kept
Facility Comments:
5.4.1.6 Adequate and appropriate hand hygiene facilities including alcohol-based hand rub shall
be available in all patient, staff and visitor areas.
1. Availability and appropriate hand washing facilities in all patient,
EVIDENCE OF
staff and visitor areas.

COMPLIANCE
2. Availability of alcohol-based hand rubs in all patient, staff and

visitor areas.
Facility Comments:

TOPIC 5.5: SAFETY AND PERFORMANCE IMPROVEMENT ACTIVITIES
STANDARD The Head of PCI Services and AMS Team shall ensure the provision of safe and quality performance with staff involvement in the continuous safety
5.5.1 and performance improvement activities of the PCI and AMS relevant activities. This can be achieved through actively monitoring and tracking risks
and trends in healthcare associated infections and antibiotic prescription pattern.
SURVEYOR FINDINGS
SELF
RATING
5.5.1.1 There are planned and systematic safety and performance improvement activities to
monitor and evaluate the performance of the PCI services and AMS relevant activities.
The process includes:
a) Data collection
b) Action plan for improvement based on existing data
c) Implementation of action plan using PDSA concept
d) Re-evaluation for improvement
e) Monitoring and evaluation of the performance
Innovation is advocated.
1. Planned performance improvement activities include (a) to (e)

2. Records on performance improvement activities.
3. Minutes of performance improvement meetings

4. Performance improvement studies
5. Records on innovation if available

Facility Comments:
5.5.1.2 The Head of PCI services and AMS relevant activities. has assigned the responsibilities
for planning, monitoring and managing safety and performance improvement activities
to appropriate individual/ personnel/ committee

1. Minutes of meetings
EVIDENCE OF
COMPLIANCE
2. Letter of assignment of responsibilities
3. Terms of Reference/Job description
Facility Comments:
5.5.1.3 The Head of PCI Services shall ensure that the staff are trained in outbreak
management. The outbreak shall be promptly investigated, and appropriate action
taken. Report is forwarded to the Person in Charge (PIC) of the Facility.
1. System for outbreak management and reporting is in place, which
include:
a) Protocol on outbreak management
b) Methodology of outbreak management
c) Register/records of outbreak
EVIDENCE OF
COMPLIANCE
2. Training of staff
3. Completed outbreak reports
4. Corrective and preventive action plans
5. Minutes of meetings
6. Acknowledgment by Head of Service and PIC/Hospital Director
7. Feedback given to staff regarding outbreak
Facility Comments:
5.5.1.4 For Infection Control, there is tracking, and trending of specific performance indicators
CORE not limited to but at least two (2) of the following:
a) percentage of staff trained in Prevention and Control of Infection practices
b) Rate of healthcare associated infections
c) number of resistant organisms to antibiotics within a specified period of time
For Antimicrobial stewardship, there is tracking, and trending of specific performance
indicators for at least one (1) of the following:
a) percentage of appropriate and complete antimicrobial prescriptions
b) percentage of prescriptions with indications that are in keeping with national
or local antimicrobial guidelines
c) Percentage of empirical prescriptions that are reviewed by 72 hours

1. Specific performance indicators monitored.

• PCI
• AMS
2. Records on tracking and trending analysis.
• PCI
• AMS
3. Remedial measures taken where appropriate
• PCI
• AMS
4. Monitoring of PCI indicators:
a)
i). 100% link nurses/link personnel to undergo minimum
three (3) days training
ii). 100% of new staff including medical practitioners given
orientation on infection control within 3 months
iii). 85% of existing staff including medical practitioners
trained on infection control.
EVIDENCE OF
COMPLIANCE
b)
i).Healthcare associated infection rate based on current
national targets (Target: less than 5%)
ii). Clinical based surveillance:
• Surgical Site Infection of selected operation based on
current local / national / international targets (e.g. clean
operation less than 2%);
• Catheter Associated Urinary Tract Infection (CAUTI);
• Ventilator-associated Pneumonia (VAP) based on current
local / national / international targets (Target: <10 per
1000 ventilator days)
• Catheter Related Infection (e.g. CRBSI) based on current
local / national / international targets (Target: <5 per 1000
catheter days)
c) Healthcare Associated MDRO surveillance:
i). Methicillin-resistant Staphylococcus aureus (MRSA)–
based on current national targets (Target: ≤ 0.3%)
ii). Extended spectrum beta-lactamase (ESBL) producers
E.coli (Target: ≤ 0.2%)

iii). Extended spectrum beta-lactamase (ESBL) producers –

Klebsiella pneumonia (target: ≤0.3%)
iv). Carbapenem-resistant Enterobacteriaceae (CRE) (target:
≤0.1%)
v). Acinetobacter spp (Target: ≤ 0.3%)
vi).
vancomycin-resistant enterococci (VRE) (Target: ≤
0.1%)
5. Monitoring of AMS indicators
a) Percentage of complete antimicrobial prescriptions that
contain start date, indication, dosage, route of
administration and either duration of therapy or date of
next review of the prescription
b) Percentage of prescriptions where indications are given
and the choice, dose and route of administration of the
antimicrobial is in keeping with either National or local
antimicrobial guidelines.
c) Percentage of antimicrobials started empirically that
have a documented review at 72 hours based on
updated clinical status and new investigation findings
Facility Comments:
5.5.1.5 The Facility takes appropriate actions on all notifiable emerging and re-emerging
diseases and report to the relevant authorities in accordance to regulatory requirement.
Note: Prevention and Control of Infectious Diseases Act 1988
1. Records and reports on actions taken for all notifiable,

EVIDENCE OF
emerging and re-emerging diseases that have potential to

COMPLIANCE
cause hospital outbreak.
Facility Comments:

5.5.1.6 Feedback on results of safety and performance improvement activities are regularly
communicated to the staff and relevant authority.
1. Results on safety and performance improvement activities are

accessible to staff.
EVIDENCE OF
COMPLIANCE
2. Evidence of feedback via communication on results of
performance improvement activities through continuing
education activities/meetings.
3. Minutes of service/unit/committee meetings
Facility Comments:
5.5.1.7 Appropriate documentation of safety and performance improvement activities is kept

and confidentiality of medical practitioners, staff and patients is preserved.
1. Documentation on performance improvement activities and

EVIDENCE OF
performance indicators.
COMPLIANCE
2. Policy statement on anonymity on patients and providers

involved in performance improvement activities.
Facility Comments:

SERVICE SUMMARY
SURVEYOR SUMMARY:
OVERALL RATING:
OVERALL RISK:

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MSQH Malaysian Hospital Accreditation Standards & Assessment Tool 6th Edition 2021

SURVEY ITEM &SELF-ASSESSMENT

SERVICE STANDARD 5 : PREVENTION AND CONTROL OF INFECTION

TOPIC 5.1: ORGANISATION AND MANAGEMENT

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1. Vision, Mission and values statements of the Facility are

5.1.1.2 There is an organisation chart which:

a) provides a clear representation of the structure and functions of the Facility’s

1. Clearly delineated current organisation chart with line of

2. Organisation chart of the services endorsed, dated and

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2. Terms of Reference for PCI/AMS Team members

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1. Appointment letters for link nurses/link personnel

3. Documented evidence on request for allocation of budget and

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4. Approved budget and resources – if applicable

1. Assignment letter of Head of PCI/AMS

2. Job description of Head of PCI/AMS

1. Records are available but not limited to the following:

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1. Minutes of committee meetings, e.g. Health and Safety

1. Where appropriate, records are kept on actions taken which

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a) clean and hygienic facilities;

1. There is evidence of items (a) to (h) being implemented.

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SURVEY ITEM &SELF-ASSESSMENT

TOPIC 5.2 HUMAN RESOURCE DEVELOPMENT AND MANAGEMENT

1. Records on credentials of Head of Service/Team and staff

complexity of the Facility and services).

1. Appointment/assignment letter for Head of Service

2. Description of duties and responsibilities.

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1. PCI - Post basic /advanced diploma infection control

3. On-site training records conducted by

2. Appointed pharmacist (AMS trained, when available)

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2. Job description includes specialisation skills

1. Policy requiring all new team members to attend structured

2. Records on structured orientation programme

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1. Training needs assessment is carried out and gaps identified.

2. Training on safety measures in high risks areas such as the

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1. Facility-wide orientation programme

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SURVEY ITEM &SELF-ASSESSMENT

TOPIC 5.3: POLICIES AND PROCEDURES

1. Facility-wide infection control policies and procedures which are

b) fight against antimicrobial resistance;

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Cross departmental collaboration is practised in developing relevant policies and

1. Training and briefing on the current policies and

2. Circulation list and acknowledgement.

1. Infection control practices (on-site observation) in each of the

4. Staff health status report on cases related to infection control

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1. Copies of policies and procedures, protocols, guidelines,