Part 5: Infection prevention and antimicrobial stewardship

Section 5.1: Governance

Criterion 5.1.1

Guidance for all providers

  • The governance body develops IP and AMS programmes that align with the organisation’s strategic document and reviews them annually.
  • The content and detail are appropriate to the size, complexity, and degree of risk associated with the services provided.
  • The governance body knows and understands its responsibilities for delivering the IP and AMS programmes and seeks additional support where needed to fulfil these responsibilities.
  • Service providers adequately resource their IP and AMS programme activities.

Criterion 5.1.2

Guidance for all providers

  • The service provider has a clear structure that enables access to IP and AMS expertise and a clearly defined process for accessing this advice.  

Criterion 5.1.3

Guidance for all providers

  • Under the service provider’s arrangements, executive clinical management or clinical governance address IP and AMS issues.
  • Escalation may be linked to emergency management procedures and processes.
  • Governing bodies are responsive to IP and AMS situations, including health care-associated infections (HAI). 
  • The IP team or personnel facilitate activation of outbreak and pandemic plans in consultation with the local public health team if there are wider community implications. The governance body oversees the response. It may be necessary to involve other relevant services and co-opt them as required and in line with national and regional guidance.
  • If an outbreak occurs, activation includes education and communication strategies for people receiving services and their whānau, access holders, and contractors.

Criterion 5.1.4

Guidance for all providers

  • The service provider has strategic, operational, and quality improvement systems, with clinical governance oversight to demonstrate its compliance with infection prevention and AMS policies.
  • The service provider agrees and monitors key performance indicators for IP and AMS. Executive leadership receives, reports on, and acts on these. Where possible, benchmarking with comparable organisations occurs.
  • A culture of learning from significant events is evident where adverse events, including outbreaks and incidents, promote system change and reduce risks.

Section 5.2: The infection prevention programme and implementation

Criterion 5.2.1

Guidance for all providers

  • Where multidisciplinary IP expertise is not available within a service, the service provider has a defined process for gaining advice and support on infection prevention, infectious disease, or clinical microbiology.
  • A position description, terms of reference, or  similar document clearly states the responsibilities, functions, and allocated hours of work of the IP role and personnel.
  • The IP role or personnel have access to the necessary tools (such as standards, guidelines, and evidence-informed literature) to perform their function.
  • Service providers support the IP role or personnel to develop the skills they need to meet the requirements of the role.

Criterion 5.2.2

Guidance has not been developed for this criterion.

Guidance is related to the infection prevention plan for an organization. It needs to include:

  • If the plan is developed by IP personnel
  • The plan details a timeframe for annual review against strategic company/hospital/facility objectives
  • Links to the quality improvement programme for an organization

Criterion 5.2.3

Guidance for all providers

  • Examples of policies for built environment include policies for ventilation, water, and renovation and construction. 
  • The IP suite of policies may also include:
    1. procurement (see 5.2.7)
    2. waste management (see 5.5.1)
    3. cleaning (see 5.5.3)
    4. laundry (see 5.5.4).

Additional guidance

Fertility services
  • Infection prevention in assisted reproductive technology covers the distinct aspects of: 
    1. general hygiene as for any health provider, screening of people for infection agents that may cross-contaminate in vitro culture or storage systems, screening donors for infectious agents that may be transmitted to recipients and day-stay surgery procedures
    2. prevention of cross-contamination in the liquid nitrogen storage systems
    3. prevention of cross-contamination in collection areas.

Criterion 5.2.4

Guidance for all providers

  • Service providers have a pandemic response plan with clearly defined roles and communication pathways. This may be linked to the emergency response process.
  • The plan reflects national and regional policy or guidance.
  • The IP team or committee facilitates activation of outbreak and pandemic plans. It may be necessary to involve other relevant services and co-opt them as required.
  • Service providers arrange for pandemic response education that includes hand hygiene and the appropriate use, removal, and disposal of PPE. Updates are delivered at defined intervals to verify ongoing compliance and competency.
  • The provision of education and communication of information during a pandemic or outbreak situation are part of the pandemic response plan.
  • PPE stock rotation occurs so it remains fit for purpose. Service providers observe expiry dates and maintain the integrity of the product.

Criterion 5.2.5

Guidance for all providers

  • IP personnel may have input into the following policies:
    1. insertion, management, and removal of invasive, indwelling medical devices
    2. aseptic technique
    3. food safety
    4. new procedures or processes that may influence the risk of infection.
  • Service providers carry out procedures requiring asepsis in a suitable, clean environment.

Criterion 5.2.6

Guidance for all providers

  • Education for health care and support workers:
    1. is tailored to meet the needs of various roles and responsibilities
    2. occurs in a manner that recognises and meets their communication method, style, and preference
    3. is easy for all people to access, understand, and use, enact, or follow.
    4. is based on evidence-informed practice.
  • Service providers assess the IP education and training needs of all health care and support workers through assessment and review processes; for example, via performance management reviews.
  • Service providers evaluate the provision, quality, and uptake of IP education and maintain education records of health care and support workers.
  • All health care and support workers receive education on IP risk assessment and how to apply this to implementation of standard precautions.
  • Service providers have multiple and integrated approaches to deliver IP education across all professions and disciplines.
  • Education for people using the service:
    1. occurs in a manner that recognises and meets their communication method, style, and preference
    2. is recorded in their health record
    3. is easy for all people to access, understand, and use, enact, or follow.
    4. may be reviewed by using health literacy tools; for example, Ministry of Health (2015) A Framework for Health Literacy.
  • Service providers also provide visitors with education as required; for example, during outbreaks of infection.

Criterion 5.2.7

Guidance for all providers

  • Service providers have clear, documented processes for accessing IP advice during procurement. This process includes providing an evaluation of the decontamination and reprocessing requirements for the medical equipment or device.
  • IP-related products, including PPE, are of an acceptable quality and conform to relevant minimum standards.

Criterion 5.2.8

Guidance for all providers

  • IP role and personnel are involved in any new build or renovation from design phase to completion.
  • The policy on the built environment sets out the process for early consultation.
  • The process for consultation includes changes to ratios of health care and support workers to outsourced contracts that could impact on IP.

Criterion 5.2.9

Guidance for all providers

  • Service providers reprocess medical devices in line with relevant standards; for example, AS/NZ 4187.
  • Where disinfection and sterilisation of reusable medical devices occur, these procedures are appropriately aligned with accepted best practice standards.
  • Where mechanical equipment is used in these procedures, it complies with relevant standards.
  • Where sterilisation of reusable medical devices is not applicable, service providers still have appropriate decontamination procedures in place for equipment and devices used in the delivery of care.  

Criterion 5.2.10

Aged care: Guidance
  • Service providers are able to demonstrate via audit that they have checks in place to verify that they have sterilised equipment before using it.
Fertility services: Guidance
  • Service providers are able to demonstrate via audit that they have checks in place to verify that they have sterilised equipment before using it.
Public/private hospital: Guidance
  • Automated reprocessing has continuous quality monitoring processes in place where possible.
  • Service providers audit procedures for reprocessing reusable medical devices at least annually.  
  • External audit is recommended for high-risk reprocessing of reusable medical devices (for example, sterile services and endoscope reprocessing) where possible.  
  • The service provider has a process for critical equipment track and trace to the person receiving services.
  • Service providers are able to demonstrate via audit that they have checks in place to verify that they have sterilised equipment before using it.
Birthing units: Guidance
  • Automated reprocessing has continuous quality monitoring processes in place where possible.
  • Service providers audit procedures for reprocessing reusable medical devices at least annually.  
  • External audit is recommended for high-risk reprocessing of reusable medical devices (for example, sterile services and endoscope reprocessing) where possible.  
  • The service provider has a process for critical equipment track and trace to the person receiving services.
  • Service providers are able to demonstrate via audit that they have checks in place to verify that they have sterilised equipment before using it.
Hospice: Guidance
  • Service providers are able to demonstrate via audit that they have checks in place to verify that they have sterilised equipment before using it.
Abortion services: Guidance
  • Service providers are able to demonstrate via audit that they have checks in place to verify that they have sterilised equipment before using it.

Criterion 5.2.11

Aged care: Guidance
  • Reprocessing constitutes remanufacturing. Service providers will not reprocess single-use medical devices for which they do not have validated cleaning instructions or procedures, regulatory registrations and associated technical documentation.
Public/private hospital: Guidance
  • Reprocessing constitutes remanufacturing. Service providers will not reprocess single-use medical devices for which they do not have validated cleaning instructions or procedures, regulatory registrations and associated technical documentation.
Birthing units: Guidance
  • Reprocessing constitutes remanufacturing. Service providers will not reprocess single-use medical devices for which they do not have validated cleaning instructions or procedures, regulatory registrations and associated technical documentation.
Hospice: Guidance
  • Reprocessing constitutes remanufacturing. Service providers will not reprocess single-use medical devices for which they do not have validated cleaning instructions or procedures, regulatory registrations and associated technical documentation.
Abortion services: Guidance
  • Reprocessing constitutes remanufacturing. Service providers will not reprocess single-use medical devices for which they do not have validated cleaning instructions or procedures, regulatory registrations and associated technical documentation.

Criterion 5.2.12

Guidance for all providers

  • Service providers seek feedback on information and education on infection prevention that they provide in te reo Māori.

Criterion 5.2.13

Guidance for all providers

  • Service providers can evidence that they take a partnership approach with Māori to provide culturally safe practice in IP.
  • Service providers proactively seek feedback from Māori who access these services and make changes or improvements based on their recommendations.

Additional guidance

Public/private hospital
  • Service providers do not see birth as a sterile procedure, except when it involves a caesarean section. Infection prevention for the person giving birth, baby, and health care and support workers is important. For example, service providers support and encourage cultural practices such as use of muka pito ties for tying the umbilical cord.
Birthing units
  • Service providers do not see birth as a sterile procedure, except when it involves a caesarean section. Infection prevention for the person giving birth, baby, and health care and support workers is important. For example, service providers support and encourage cultural practices such as use of muka pito ties for tying the umbilical cord.

Section 5.3: Antimicrobial stewardship programme and implementation 

Criterion 5.3.1

Aged care: Guidance
  • For a residential home or facility, prescribers are responsible for ensuring people receiving services use antimicrobials appropriately and in line with relevant evidence-based guidance, expert advice, and susceptibility findings.
  • In these settings, service providers support AMS through:
    1. working to reduce inappropriate antibiotic prescribing by preventing infections in the care setting
    2. discouraging laboratory testing without a clear indication, which may otherwise drive antimicrobial use
    3. discouraging antimicrobial use, including topically, unless it is to treat a current infection for a defined period
    4. promoting appropriate antimicrobial agents for clear indications, including with the message that antimicrobials are not useful for viral illnesses and topical agents are rarely used.
  • The local diagnostic laboratory provides information on the antimicrobial susceptibility patterns of significant clinical isolates to support empiric use of antimicrobials and makes this information available to the relevant clinical health care workers, the prescriber, and the service provider. It provides this information at least annually.
  • Service providers review relevant antimicrobial susceptibility patterns to inform antimicrobial prescribing in the service.
Fertility services: Guidance
  • The local diagnostic laboratory provides information on the antimicrobial susceptibility patterns of significant clinical isolates to support empiric use of antimicrobials and makes this information available to the relevant clinical health care workers, the prescriber, and the service provider. It provides this information at least annually.
  • Service providers review relevant antimicrobial susceptibility patterns to inform antimicrobial prescribing in the service.
Residential disability: Guidance
  • For a residential home or facility, prescribers are responsible for ensuring people receiving services use antimicrobials appropriately and in line with relevant evidence-based guidance, expert advice, and susceptibility findings.
  • In these settings, service providers support AMS through:
    1. working to reduce inappropriate antibiotic prescribing by preventing infections in the care setting
    2. discouraging laboratory testing without a clear indication, which may otherwise drive antimicrobial use
    3. discouraging antimicrobial use, including topically, unless it is to treat a current infection for a defined period
    4. promoting appropriate antimicrobial agents for clear indications, including with the message that antimicrobials are not useful for viral illnesses and topical agents are rarely used.
  • The local diagnostic laboratory provides information on the antimicrobial susceptibility patterns of significant clinical isolates to support empiric use of antimicrobials and makes this information available to the relevant clinical health care workers, the prescriber, and the service provider. It provides this information at least annually.
  • Service providers review relevant antimicrobial susceptibility patterns to inform antimicrobial prescribing in the service.
Public/private hospital: Guidance
  • The local diagnostic laboratory provides information on the antimicrobial susceptibility patterns of significant clinical isolates to support empiric use of antimicrobials and makes this information available to the relevant clinical health care workers, the prescriber, and the service provider. It provides this information at least annually.
  • Service providers review relevant antimicrobial susceptibility patterns to inform antimicrobial prescribing in the service.
Birthing units: Guidance
  • The local diagnostic laboratory provides information on the antimicrobial susceptibility patterns of significant clinical isolates to support empiric use of antimicrobials and makes this information available to the relevant clinical health care workers, the prescriber, and the service provider. It provides this information at least annually.
  • Service providers review relevant antimicrobial susceptibility patterns to inform antimicrobial prescribing in the service.
Hospice: Guidance
  • The local diagnostic laboratory provides information on the antimicrobial susceptibility patterns of significant clinical isolates to support empiric use of antimicrobials and makes this information available to the relevant clinical health care workers, the prescriber, and the service provider. It provides this information at least annually.
  • Service providers review relevant antimicrobial susceptibility patterns to inform antimicrobial prescribing in the service.
Abortion services: Guidance
  • The local diagnostic laboratory provides information on the antimicrobial susceptibility patterns of significant clinical isolates to support empiric use of antimicrobials and makes this information available to the relevant clinical health care workers, the prescriber, and the service provider. It provides this information at least annually.
  • Service providers review relevant antimicrobial susceptibility patterns to inform antimicrobial prescribing in the service.

Criterion 5.3.2

Public/private hospital: Guidance
  • The AMS policies or guidance on targeted antimicrobial therapy as well as prophylaxis are accessible to relevant health care and support workers who are involved in antimicrobial use. 
Service providers communicate any changes in policy and guidance on antimicrobial practice to health care and support workers in a timely manner.
  • Sufficient resources to support appropriate antimicrobial prescribing and use are readily available.

Criterion 5.3.3

Aged care: Guidance
  • The local diagnostic laboratory provides information on the antimicrobial susceptibility patterns of significant clinical isolates to support empiric use of antimicrobials and makes it available to the relevant clinical health care workers, the prescriber, and the service provider. It provides this information at least annually.
  • Service providers review relevant antimicrobial susceptibility patterns to inform antimicrobial prescribing in the service.
  • Service providers undertake internal audits to evaluate antimicrobial use and how well it aligns with relevant evidence-informed guidance and quality improvement initiatives for antimicrobial prescribing. 
  • Service providers report on the effectiveness of AMS initiatives and their compliance with evidence-informed guidelines at defined intervals to the governance body. This reporting will identify the appropriateness of antimicrobial prescribing and areas for improvement.
  • Service providers provide an education strategy for clinicians who are involved in antimicrobial medication and patients.
Fertility services: Guidance
  • The local diagnostic laboratory provides information on the antimicrobial susceptibility patterns of significant clinical isolates to support empiric use of antimicrobials and makes it available to the relevant clinical health care workers, the prescriber, and the service provider. It provides this information at least annually.
  • Service providers review relevant antimicrobial susceptibility patterns to inform antimicrobial prescribing in the service.
  • Service providers undertake internal audits to evaluate antimicrobial use and how well it aligns with relevant evidence-informed guidance and quality improvement initiatives for antimicrobial prescribing. 
  • Service providers report on the effectiveness of AMS initiatives and their compliance with evidence-informed guidelines at defined intervals to the governance body. This reporting will identify the appropriateness of antimicrobial prescribing and areas for improvement.
  • Service providers provide an education strategy for clinicians who are involved in antimicrobial medication and patients.
Residential disability: Guidance
  • The local diagnostic laboratory provides information on the antimicrobial susceptibility patterns of significant clinical isolates to support empiric use of antimicrobials and makes it available to the relevant clinical health care workers, the prescriber, and the service provider. It provides this information at least annually.
  • Service providers review relevant antimicrobial susceptibility patterns to inform antimicrobial prescribing in the service.
  • Service providers undertake internal audits to evaluate antimicrobial use and how well it aligns with relevant evidence-informed guidance and quality improvement initiatives for antimicrobial prescribing. 
  • Service providers report on the effectiveness of AMS initiatives and their compliance with evidence-informed guidelines at defined intervals to the governance body. This reporting will identify the appropriateness of antimicrobial prescribing and areas for improvement.
  • Service providers provide an education strategy for clinicians who are involved in antimicrobial medication and patients.
Public/private hospital: Guidance
  • The local diagnostic laboratory provides information on the antimicrobial susceptibility patterns of significant clinical isolates to support empiric use of antimicrobials and makes it available to the relevant clinical health care workers, the prescriber, and the service provider. It provides this information at least annually.
  • Service providers review relevant antimicrobial susceptibility patterns to inform antimicrobial prescribing in the service.
  • Service providers undertake internal audits to evaluate antimicrobial use and how well it aligns with relevant evidence-informed guidance and quality improvement initiatives for antimicrobial prescribing. 
  • Service providers report on the effectiveness of AMS initiatives and their compliance with evidence-informed guidelines at defined intervals to the governance body. This reporting will identify the appropriateness of antimicrobial prescribing and areas for improvement.
  • Service providers provide an education strategy for clinicians who are involved in antimicrobial medication and patients.
  • The AMS programme provides reports that include information about empirical prescribing, prophylaxis (where applicable), audit findings, and controls to manage the use of restricted antimicrobials.
Hospice: Guidance
  • The local diagnostic laboratory provides information on the antimicrobial susceptibility patterns of significant clinical isolates to support empiric use of antimicrobials and makes it available to the relevant clinical health care workers, the prescriber, and the service provider. It provides this information at least annually.
  • Service providers review relevant antimicrobial susceptibility patterns to inform antimicrobial prescribing in the service.
  • Service providers undertake internal audits to evaluate antimicrobial use and how well it aligns with relevant evidence-informed guidance and quality improvement initiatives for antimicrobial prescribing. 
  • Service providers report on the effectiveness of AMS initiatives and their compliance with evidence-informed guidelines at defined intervals to the governance body. This reporting will identify the appropriateness of antimicrobial prescribing and areas for improvement.
  • Service providers provide an education strategy for clinicians who are involved in antimicrobial medication and patients.

Section 5.4: Surveillance of health care-associated infection

Criterion 5.4.1

Guidance for all providers (except home and community)
  • Service providers have adequate resources, expertise, and systems to collect and analyse surveillance data.
  • Service providers should use electronic systems where possible to facilitate surveillance processes.
  • When surveillance activities identify issues, service providers appropriately investigate, report on, and act on them in a timely manner
  • Service providers have systems to:
    1. monitor and investigate laboratory reported infections, including multi-drug resistant organisms
    2. monitor and investigate infections while providing care.
  • There is access to shared clinical record and laboratory results to support surveillance activities.
  • Service providers demonstrate formal processes for reporting communicable disease to Community and Public Health and how it accesses support if required.

Criterion 5.4.2

Guidance for all providers (except home and community)
  • Service providers develop a surveillance plan and their governing body endorses it.
  • The plan should include participation in national and regional quality improvement and surveillance programmes where possible.
  • Surveillance activities may include monitoring and reporting of:
    1. HAIs, including adverse events and treatment injuries that may result from them
    2. specific types of infections and colonisation that may pose particular risk to users of the service
    3. critical incidents.

Criterion 5.4.3

Aged care: Guidance
  • A programme of surveillance, appropriate to the size and setting of the service, is in place.
  • Service providers use standardised surveillance definitions to identify and classify infection events that relate to the type of infection under surveillance and are provided by recognised authorities.
  • Data collection tools should be validated and, if required, access to appropriate expertise for analysing the results is available.
  • Data analysis may include the number and type of events being monitored during a defined time period. This is to support comparison over time and also to measure the effectiveness of continuous quality improvement interventions. Where possible, the analysis should take account of the demographics of the people receiving services, including ethnicity.
  • Service providers should benchmark surveillance data with comparable organisations where possible.
Residential disability: Guidance
  • A programme of surveillance, appropriate to the size and setting of the service, is in place.
  • Service providers use standardised surveillance definitions to identify and classify infection events that relate to the type of infection under surveillance and are provided by recognised authorities.
  • Data collection tools should be validated and, if required, access to appropriate expertise for analysing the results is available.
  • Data analysis may include the number and type of events being monitored during a defined time period. This is to support comparison over time and also to measure the effectiveness of continuous quality improvement interventions. Where possible, the analysis should take account of the demographics of the people receiving services, including ethnicity.
  • Service providers should benchmark surveillance data with comparable organisations where possible.
Residential mental health and alcohol and other drug: Guidance
  • A programme of surveillance, appropriate to the size and setting of the service, is in place.
  • Service providers use standardised surveillance definitions to identify and classify infection events that relate to the type of infection under surveillance and are provided by recognised authorities.
  • Data collection tools should be validated and, if required, access to appropriate expertise for analysing the results is available.
  • Data analysis may include the number and type of events being monitored during a defined time period. This is to support comparison over time and also to measure the effectiveness of continuous quality improvement interventions. Where possible, the analysis should take account of the demographics of the people receiving services, including ethnicity.
  • Service providers should benchmark surveillance data with comparable organisations where possible.
Public/private hospital: Guidance
  • A programme of surveillance, appropriate to the size and setting of the service, is in place.
  • Service providers use standardised surveillance definitions to identify and classify infection events that relate to the type of infection under surveillance and are provided by recognised authorities.
  • Data collection tools should be validated and, if required, access to appropriate expertise for analysing the results is available.
  • Data analysis may include the number and type of events being monitored during a defined time period. This is to support comparison over time and also to measure the effectiveness of continuous quality improvement interventions. Where possible, the analysis should take account of the demographics of the people receiving services, including ethnicity.
  • Service providers should benchmark surveillance data with comparable organisations where possible.
Birthing units: Guidance
  • A programme of surveillance, appropriate to the size and setting of the service, is in place.
  • Service providers use standardised surveillance definitions to identify and classify infection events that relate to the type of infection under surveillance and are provided by recognised authorities.
  • Data collection tools should be validated and, if required, access to appropriate expertise for analysing the results is available.
  • Data analysis may include the number and type of events being monitored during a defined time period. This is to support comparison over time and also to measure the effectiveness of continuous quality improvement interventions. Where possible, the analysis should take account of the demographics of the people receiving services, including ethnicity.
  • Service providers should benchmark surveillance data with comparable organisations where possible.
Hospice: Guidance
  • A programme of surveillance, appropriate to the size and setting of the service, is in place.
  • Service providers use standardised surveillance definitions to identify and classify infection events that relate to the type of infection under surveillance and are provided by recognised authorities.
  • Data collection tools should be validated and, if required, access to appropriate expertise for analysing the results is available.
  • Data analysis may include the number and type of events being monitored during a defined time period. This is to support comparison over time and also to measure the effectiveness of continuous quality improvement interventions. Where possible, the analysis should take account of the demographics of the people receiving services, including ethnicity.
  • Service providers should benchmark surveillance data with comparable organisations where possible.
Abortion services: Guidance
  • A programme of surveillance, appropriate to the size and setting of the service, is in place.
  • Service providers use standardised surveillance definitions to identify and classify infection events that relate to the type of infection under surveillance and are provided by recognised authorities.
  • Data collection tools should be validated and, if required, access to appropriate expertise for analysing the results is available.
  • Data analysis may include the number and type of events being monitored during a defined time period. This is to support comparison over time and also to measure the effectiveness of continuous quality improvement interventions. Where possible, the analysis should take account of the demographics of the people receiving services, including ethnicity.
  • Service providers should benchmark surveillance data with comparable organisations where possible.

Criterion 5.4.4

Aged care: Guidance
  • Service providers prepare a summary of surveillance activities and submit it to their governing body at defined intervals. As well as monitoring HAIs, this summary evaluates the effectiveness of the surveillance programme and identifies any areas for improvement. 
  • The IP role or personnel reviews, analyses, and interprets the surveillance data and produces a report with recommendations.
  • The surveillance report identifies new, emergent, or re-emerging infection-related risks.
  • The governance body provides oversight of the implementation of recommendations.
  • Relevant people to share the results with include health care and support workers, the person receiving services and their whānau.
  • Results of the surveillance and recommendations are easy for all people to access, understand and use.
Fertility services: Guidance
  • Service providers prepare a summary of surveillance activities and submit it to their governing body at defined intervals. As well as monitoring HAIs, this summary evaluates the effectiveness of the surveillance programme and identifies any areas for improvement. 
  • The IP role or personnel reviews, analyses, and interprets the surveillance data and produces a report with recommendations.
  • The surveillance report identifies new, emergent, or re-emerging infection-related risks.
  • The governance body provides oversight of the implementation of recommendations.
  • Relevant people to share the results with include health care and support workers, the person receiving services and their whānau.
  • Results of the surveillance and recommendations are easy for all people to access, understand and use.
Residential disability: Guidance
  • Service providers prepare a summary of surveillance activities and submit it to their governing body at defined intervals. As well as monitoring HAIs, this summary evaluates the effectiveness of the surveillance programme and identifies any areas for improvement. 
  • The IP role or personnel reviews, analyses, and interprets the surveillance data and produces a report with recommendations.
  • The surveillance report identifies new, emergent, or re-emerging infection-related risks.
  • The governance body provides oversight of the implementation of recommendations.
  • Relevant people to share the results with include health care and support workers, the person receiving services and their whānau.
  • Results of the surveillance and recommendations are easy for all people to access, understand and use.
Residential mental health and alcohol and other drug: Guidance
  • Service providers prepare a summary of surveillance activities and submit it to their governing body at defined intervals. As well as monitoring HAIs, this summary evaluates the effectiveness of the surveillance programme and identifies any areas for improvement. 
  • The IP role or personnel reviews, analyses, and interprets the surveillance data and produces a report with recommendations.
  • The surveillance report identifies new, emergent, or re-emerging infection-related risks.
  • The governance body provides oversight of the implementation of recommendations.
  • Relevant people to share the results with include health care and support workers, the person receiving services and their whānau.
  • Results of the surveillance and recommendations are easy for all people to access, understand and use.
Public/private hospital: Guidance
  • Service providers prepare a summary of surveillance activities and submit it to their governing body at defined intervals. As well as monitoring HAIs, this summary evaluates the effectiveness of the surveillance programme and identifies any areas for improvement. 
  • The IP role or personnel reviews, analyses, and interprets the surveillance data and produces a report with recommendations.
  • The surveillance report identifies new, emergent, or re-emerging infection-related risks.
  • The governance body provides oversight of the implementation of recommendations.
  • Relevant people to share the results with include health care and support workers, the person receiving services and their whānau.
  • Results of the surveillance and recommendations are easy for all people to access, understand and use.
Birthing units: Guidance
  • Service providers prepare a summary of surveillance activities and submit it to their governing body at defined intervals. As well as monitoring HAIs, this summary evaluates the effectiveness of the surveillance programme and identifies any areas for improvement. 
Hospice: Guidance
  • Service providers prepare a summary of surveillance activities and submit it to their governing body at defined intervals. As well as monitoring HAIs, this summary evaluates the effectiveness of the surveillance programme and identifies any areas for improvement. 
  • The IP role or personnel reviews, analyses, and interprets the surveillance data and produces a report with recommendations.
  • The surveillance report identifies new, emergent, or re-emerging infection-related risks.
  • The governance body provides oversight of the implementation of recommendations.
  • Relevant people to share the results with include health care and support workers, the person receiving services and their whānau.
  • Results of the surveillance and recommendations are easy for all people to access, understand and use.
Abortion services: Guidance
  • Service providers prepare a summary of surveillance activities and submit it to their governing body at defined intervals. As well as monitoring HAIs, this summary evaluates the effectiveness of the surveillance programme and identifies any areas for improvement. 
  • The IP role or personnel reviews, analyses, and interprets the surveillance data and produces a report with recommendations.
  • The surveillance report identifies new, emergent, or re-emerging infection-related risks.
  • The governance body provides oversight of the implementation of recommendations.
  • Relevant people to share the results with include health care and support workers, the person receiving services and their whānau.
  • Results of the surveillance and recommendations are easy for all people to access, understand and use.

Criterion 5.4.5

Guidance for all providers (except home and community)
  • Service providers have processes for communication with people receiving services.
  • Service providers document their communication with each person receiving their services in the person’s record.
  • During and after investigation, service providers provide feedback on progress and the outcome to the person receiving services and their whānau.

Section 5.5: Environment

Criterion 5.5.1

Guidance for all providers

  • Safe and appropriate storage and disposal of waste may include prevention strategies, prompt action, and management in line with relevant waste standards.
  • Service providers meet their contractual requirements.

Criterion 5.5.2

Guidance for all providers

  • Service providers provide suitable PPE appropriate to the risks involved for those handling waste or hazardous substances.

Criterion 5.5.3

Guidance for all providers

  • Service providers provide suitable PPE for those who are performing the cleaning.
  • A procurement and contract review process is in place to check that cleaning and disinfection products are fit for purpose.
  • Cleaning contractors and their employees understand and follow recognised guidelines.

Additional guidance

Fertility services
  • Cleaning products take into account embryo-toxicity risks.
Residential disability
  • Cleaning services fit the situation of the people living in the house. 
Residential mental health and alcohol and other drug
  • Cleaning services fit the situation of the people living in the house. 
Public/private hospital
  • Service providers have procedures to support practice for cleaning seclusion rooms between patients. 

Criterion 5.5.4

Aged care: Guidance
  • Service providers may meet relevant laundry standards that apply to the service they are providing.
  • Training is appropriate to the role.
  • Service providers have an implemented process for transporting/moving dirty linen within the facility.
  • Single, remote, or rural service providers show evidence that they have taken measures to meet the intent of the standard.
  • Service providers demonstrate a commitment to cultural safety by separating items that are sent to the laundry; for example, tea towels are separated from other linen. Items that touch the head or face (for example, pillowcases and face cloths) are not used on other parts of the body. See sector guidance for criterion 3.5.7.
  • Service providers wash all personal clothing or items separately from other linen.
  • Service providers have an implemented process to manage residents’ clothing and personal items.
Fertility services: Guidance
  • Service providers may meet relevant laundry standards that apply to the service they are providing.
  • Training is appropriate to the role.
  • Service providers have an implemented process for transporting/moving dirty linen within the facility.
  • Single, remote, or rural service providers show evidence that they have taken measures to meet the intent of the standard.
  • Service providers demonstrate a commitment to cultural safety by separating items that are sent to the laundry; for example, tea towels are separated from other linen. Items that touch the head or face (for example, pillowcases and face cloths) are not used on other parts of the body. See sector guidance for criterion 3.5.7.
Residential disability: Guidance
  • Service providers may meet relevant laundry standards that apply to the service they are providing.
  • Training is appropriate to the role.
  • Service providers have an implemented process for transporting/moving dirty linen within the facility.
  • Single, remote, or rural service providers show evidence that they have taken measures to meet the intent of the standard.
  • Service providers demonstrate a commitment to cultural safety by separating items that are sent to the laundry; for example, tea towels are separated from other linen. Items that touch the head or face (for example, pillowcases and face cloths) are not used on other parts of the body. See sector guidance for criterion 3.5.7.
  • Service providers wash all personal clothing or items separately from other linen.
  • Service providers have an implemented process to manage residents’ clothing and personal items.
Residential mental health and alcohol and other drug: Guidance
  • Service providers may meet relevant laundry standards that apply to the service they are providing.
  • Training is appropriate to the role.
  • Service providers have an implemented process for transporting/moving dirty linen within the facility.
  • Single, remote, or rural service providers show evidence that they have taken measures to meet the intent of the standard.
  • Service providers demonstrate a commitment to cultural safety by separating items that are sent to the laundry; for example, tea towels are separated from other linen. Items that touch the head or face (for example, pillowcases and face cloths) are not used on other parts of the body. See sector guidance for criterion 3.5.7.
  • Service providers wash all personal clothing or items separately from other linen.
  • Service providers have an implemented process to manage residents’ clothing and personal items.
Public/private hospital: Guidance
  • Service providers may meet relevant laundry standards that apply to the service they are providing.
  • Training is appropriate to the role.
  • Service providers have an implemented process for transporting/moving dirty linen within the facility.
  • Single, remote, or rural service providers show evidence that they have taken measures to meet the intent of the standard.
  • Service providers demonstrate a commitment to cultural safety by separating items that are sent to the laundry; for example, tea towels are separated from other linen. Items that touch the head or face (for example, pillowcases and face cloths) are not used on other parts of the body. See sector guidance for criterion 3.5.7.
Birthing units: Guidance
  • Service providers may meet relevant laundry standards that apply to the service they are providing.
  • Training is appropriate to the role.
  • Service providers have an implemented process for transporting/moving dirty linen within the facility.
  • Single, remote, or rural service providers show evidence that they have taken measures to meet the intent of the standard.
  • Service providers demonstrate a commitment to cultural safety by separating items that are sent to the laundry; for example, tea towels are separated from other linen. Items that touch the head or face (for example, pillowcases and face cloths) are not used on other parts of the body. See sector guidance for criterion 3.5.7.
Hospice: Guidance
  • Service providers may meet relevant laundry standards that apply to the service they are providing.
  • Training is appropriate to the role.
  • Service providers have an implemented process for transporting/moving dirty linen within the facility.
  • Single, remote, or rural service providers show evidence that they have taken measures to meet the intent of the standard.
  • Service providers demonstrate a commitment to cultural safety by separating items that are sent to the laundry; for example, tea towels are separated from other linen. Items that touch the head or face (for example, pillowcases and face cloths) are not used on other parts of the body. See sector guidance for criterion 3.5.7.
  • Service providers wash all personal clothing or items separately from other linen.
Abortion services: Guidance
  • Service providers may meet relevant laundry standards that apply to the service they are providing.
  • Training is appropriate to the role.
  • Service providers have an implemented process for transporting/moving dirty linen within the facility.
  • Single, remote, or rural service providers show evidence that they have taken measures to meet the intent of the standard.
  • Service providers demonstrate a commitment to cultural safety by separating items that are sent to the laundry; for example, tea towels are separated from other linen. Items that touch the head or face (for example, pillowcases and face cloths) are not used on other parts of the body. See sector guidance for criterion 3.5.7.

Criterion 5.5.5

Guidance for all providers (except home and community)
  • The IP role or personnel receives regular reports from facilities on the testing required by the relevant Building Codes or Standards that are applicable to the complexity of their organisation. Facilities will consult and inform the IP role or personnel when they deviate from safe parameters.
Part 4: Person-centred and safe environment Up to First page Part 6: Restraint and seclusion

Page last updated: 28 February 2023

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