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1. Purpose


To maintain a competent and active infection prevention and control committee for effective prevention and control of healthcare associated infections (HAI) and cross contamination among patients, public and personnel.


2. Organization and Composition


The Infection Prevention and Control Committee (IPCC), is a multi-disciplinary committee. It includes representation from the hospital administration and from clinical and clinical support departments.

Each hospital is to be represented by an Infection Control focal person (ICFP) with responsibilities in infection prevention and control activities at the health facility.

 Infection Control Focal Persons are partners who help to ensure the effectiveness of infection control practices within their hospitals. Each Hospital department (Internal medicine, surgery, Paediatrics, Gynaecology and obstetrics) shall have an IPC team.


The committee members of Infection Prevention and Control Committee:

  • Clinical Director: Chairperson

  • Quality Improvement Focal Person  1

  • Infection Prevention and Control focal person .1  Co-Chair

  • Representatives IPC Clinical Departments: 4

  • Internal medicine : 1

  • Surgery: 1

  • Paediatrics: 1

  • Obstetrics and Gynaecology: 1

  • Laboratory:  1

  • Sanitation and environmental officer: 1

  • Sterilizing nurse

    NB: The Clinical director shall be the chairman of the committee and the Infection Prevention and Control focal person will be the Co-Chair. The secretary and Timekeeper will be voted among committee members

3. Responsibilities 

A. Program management

  1. Identify and prioritize infection risks throughout the organization

  2. Develop and evaluate the Infection Prevention and Control Plan

  3. Assist in the planning and development of services, and facilities in the hospital that are relevant to infection control

  4. Ensure adequate resources (Human, supplies, equipment and space) required to carry out infection prevention and control activities

  5. Advise on the purchase of equipment related to infection prevention and control

  6. Approve  all chemicals and/or equipment used for disinfection and prevention control of infection, and all methods used for sterilization within the hospital

  7. Provide oversight and advice regarding minimizing risk of infections during construction activities within the hospital

  8. Participate in the Patient safe design meetings

  9. Promote collaboration between departments regarding infection prevention and control

  10. Oversee policies regarding employees

    • Immunization

    •  Infectious disease exposure management

    • Management of health workers with infectious diseases

    • Management of staff who participate in exposure-prone procedures



B. Policies and Procedures


a)Develop, recommend and review evidence-based  infection prevention and control policies, protocols and standards to guide the infection control program

b) Ensure appropriate distribution and communication of all infection prevention and control policies, protocols, procedures and standards


C. Training and Practice

  1. Assess infection prevention and control training needs on an annual basis


  2. Develop orientation and education programs for infection prevention and control for hospital staff based on a prioritization of identified needs


  3. Provide appropriate training in current infection control practices to focal person and other staff as required

  4. Ensure staff are trained and appropriate PPE are available in all areas (clinical departments, lab, sterilization, waste collection and disposal areas, laundry, etc.) and that patients and families are educated about isolation precautions and use of PPE


D. Monitoring and Evaluation 

  1. Ensure that hospital staff comply with policies, procedures and guidelines

  2. Review quality indicator reports and provide advice on clinical and service indicators

  3. Identify infection risks for patients, staff, and visitors and develop policies and procedures to manage identified risks (e.g. isolation of infectious patients, procedures with high risk for infection, staff vaccination program, education of patient and family, etc)

  4. Ensure supervision and where necessary initiate investigations and report clusters of infections

  5. Monitor infection outbreaks and advise on their prevention and management

  6. IPC focal person should initiate surveillance and clinical audits of the hospital’s infection prevention and control practices and submission of the related reports to Hospital management

  7. With P,M&E review and analyse infection prevention and control monthly reports and provide immediate feedback report with appropriate advice and recommendations to the departments and hospital management

  8. Monitor and advise about the capabilities/practices of specific departments in relation to  hygiene and infection control

  9. Discuss, analyse and make recommendations for infection prevention and control related problems brought to them

  10. IPC focal person should report on the incidence and prevalence and alert on  highly infectious diseases

  11. Monitor and advise on specific areas for hygiene and infection control

  12. Review findings of investigations into adverse events related to infection prevention and control

  13. Ensure compliance with accreditation standards in respect to Infection Prevention and Control Services

  14. Ensure an effective Process to guide proper disposal of sharps and needles and other infectious medical waste 


4. Meeting 

The committee shall meet every month unless otherwise decided by the committee. Meetings shall be considered a quorum if five members or more than 50% are present, otherwise the meeting shall continue as an ad hoc meeting. If two successive ad hoc meetings occur, binding decisions may be taken in the second meeting. Minutes of the meetings and documentation of the recommendations made shall be kept and submitted to the hospital Health committee through the Hospital Director: Feed-back of the meeting shall be given to the concerned district hospital departments within one week of a meeting.


5. Reporting


  • The committee must submit a report of its activities to the Quality Improvement committee such reports will include advice and recommendations.

  • The minutes of all meetings of the Committee will be safely kept by Quality Improvement committee.

  • Minutes will only be circulated to members of the Committee.


6. Linkages


There are several committees that address infection prevention and control issues, which require links to the IPC.

  • Quality Improvement Committee: A representative from the IPC participates on the QI Committee and makes reports to this committee.

  • Accreditation steering Committee: A representative from the IPC participates on the QI Committee and makes reports to this committee